Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial

Abstract

Importance: How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown.

Objective: To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations.

Design, setting, and participants: 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.

Main outcomes and measures: 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.

Results: 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.

Conclusions and relevance: 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.

Trial registration: ClinicalTrials.gov Identifier: NCT02905032.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Kamath reported receiving a grant from the National Institutes of Health (NIH) during the conduct of the study. Dr Kunneman reported receiving grants from the NIH during the conduct of the study. Dr Jackson reported receiving research funding from NIH and Amgen; she reported serving on the editorial board for Circulation; she reported receiving consulting fees from American College of Cardiology and McKesson, Inc; she served as an expert witness for DeBlase Brown Everly LLP; and she reported receiving publishing royalties from UpToDate. Dr Burnett reported receiving grants from the NIH outside the submitted work. Dr Shah reported receiving grants from the NIH during the conduct of the study; and he reported receiving research support through Mayo Clinic from the Food and Drug Administration to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program, the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative, the Agency for Healthcare Research and Quality, the National Heart, Lung, and Blood Institute, the National Science Foundation, the Medical Device Innovation Consortium as part of the National Evaluation System for Health Technology, and the Patient Centered Outcomes Research Institute to develop a Clinical Data Research Network. Dr Brito reported receiving grants from the Gordon and Betty Moore Foundation during the conduct of the study. No other disclosures were reported.

Figures

Figure.. CONSORT Flow Diagram