Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial.
Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial.
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DOI：
10.1001/jamanetworkopen.2021.16009
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发表时间：
2021-07-01
影响因子：
13.8
通讯作者：
Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators
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文献类型：
--
作者：
Kamath CC;Giblon R;Kunneman M;Lee AI;Branda ME;Hargraves IG;Sivly AL;Bellolio F;Jackson EA;Burnett B;Gorr H;Torres Roldan VD;Spencer-Bonilla G;Shah ND;Noseworthy PA;Montori VM;Brito JP;Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators
房颤患者与其临床医生之间关于抗凝治疗的成本对话有哪些因素，这些对话的结果如何？在这项队列研究中，830个视听记录的遭遇和参与者调查，从一个随机试验比较房颤护理与不共享决策（SDM）工具，成本对话与使用SDM工具，与中等收入的患者，并与女性初级保健工作人员临床医生进行的咨询。成本对话与患者的决策过程有关，但与最终治疗选择无关。这些研究结果表明，SDM工具可以为在实践中促进成本对话的努力提供信息，这是将不断增加的护理成本转嫁给患者时的一个重要考虑因素。这项队列研究是一项随机临床试验的二次分析，评估了导致临床医生和房颤患者之间关于护理计划的成本对话的因素。心房颤动（AF）患者及其临床医生在制定护理计划时如何考虑成本仍是未知数。确定患者和临床医生之间关于房颤抗凝治疗费用的对话以及与这些对话相关的结局的因素。这项队列研究记录了来自SDM 4AFib随机试验的5个美国医疗中心（包括学术、社区和安全网中心）的遭遇和参与者调查，比较了使用和不使用共享决策（SDM）工具的标准AF护理。纳入的患者正在考虑抗凝治疗，并在2017年1月30日至2019年6月27日期间由其临床医生招募。分析了2019年8月至11月期间的数据。费用转换的发生率和相关因素，以及费用转换与患者对治疗费用负担的考虑和抗凝治疗的选择之间的关系。共记录了830次遭遇（在922名登记的参与者中）。患者的平均（SD）年龄为71.0（10.4）岁; 511例患者（61.6%）为男性，704例（86.0%）为白色，303例（40.9%）年收入在40 000美元至99 999美元之间，657例（79.2%）正在接受抗凝剂治疗。临床医生的平均（SD）年龄为44.8（13.2）岁; 75名临床医生（53.2%）为男性，111名（76%）为内科医生，其中约一半（69名[48.9%]）专攻内科或心脏病学。639次（77.0%）发生了成本对话，SDM组更有可能发生（378 [90%] vs 261 [64%]; OR，9.69; 95% CI，5.77-16.29）。在多变量分析中，女性临床医生更有可能进行成本对话（66 [47%]; OR，2.85; 95% CI，1.21-6.71）;顾问vs培训中的临床医生（113 [75%]; OR，4.0; 95% CI，1.4-11.1）;从事家庭医学的临床医生（24 [16%]; OR，12.12; 95% CI，2.75-53.38]），内科（35 [23%]; OR，3.82; 95% CI，1.25-11.70），或其他临床医生（21 [14%]; OR，4.90; 95%CI，1.32-18.16）;家庭年收入在40000美元至99999美元之间的患者（249 [82.2%]; OR，1.86; 95%CI，1.05-3.29），与收入低于40000美元或高于99999美元的患者相比。更多进行了成本对话的患者报告成本是他们决策的一个因素（244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI，2.43-5.50），但成本对话与抗凝剂的选择无关。成本对话是常见的，特别是对于中等收入的患者和女性和咨询级别的初级保健临床医生，以及在遇到使用SDM工具;他们与患者的治疗成本负担的考虑，但不是最终的治疗选择。随着转嫁给患者的护理成本的增加，这些发现可以为在实践中促进成本对话的努力提供信息。ClinicalTrials.gov标识符：NCT 02905032
What factors contribute to cost conversations about anticoagulation treatment between patients with atrial fibrillation and their clinicians, and what outcomes are associated with these conversations? In this cohort study of 830 audiovisual recordings of encounters and participant surveys from a randomized trial comparing atrial fibrillation care with and without a shared decision-making (SDM) tool, cost conversations were associated with the use of an SDM tool, with middle-income patients, and with consultations conducted by female primary care staff clinicians. Cost conversations were associated with patients’ decision-making processes but not final treatment choice. These findings suggest that SDM tools may inform efforts to promote cost conversations in practice, an important consideration when increasing costs of care are being passed on to patients. This cohort study, a secondary analysis of a randomized clinical trial, assesses factors contributing to cost conversations about care plans between clinicians and patients with atrial fibrillation. How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown. To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations. This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019. The incidence of and factors associated with cost conversations, and the association of cost conversations with patients’ consideration of treatment cost burden and their choice of anticoagulation. A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients’ mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians’ mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent. Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients’ consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice. ClinicalTrials.gov Identifier: NCT02905032
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