NAU publications by CHER
Faculty & staff publications
NAU faculty and staff have the opportunity to publish their findings and knowledge as authors. CHER has many researchers that have been cited multiple times in major publications for their great work. The Center for Health Equity Research has accumulated all faculty publications into one, easy to navigate database.
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Boucher, Nathan A; Bull, Janet H; Cross, Sarah H; Kirby, Christine; Davis, Kelly J; Jr., Donald Taylor H Patient, caregiver and taxpayer knowledge of palliative care and views on a model of community-based palliative care Journal Article Journal of Pain and Symptom Management, 2018. @article{Boucher2018, title = {Patient, caregiver and taxpayer knowledge of palliative care and views on a model of community-based palliative care}, author = {Nathan A Boucher and Janet H Bull and Sarah H Cross and Christine Kirby and Kelly J Davis and Donald Taylor H Jr.}, url = {https://www.sciencedirect.com/science/article/pii/S0885392418304378}, year = {2018}, date = {2018-08-25}, journal = {Journal of Pain and Symptom Management}, abstract = {Context Palliative care (PC) model delivered by two large hospices and PC providers. Objectives To understand study participants' knowledge of PC and acceptability of a new community-based PC model. Methods Semistructured interview with patients and caregivers; focus groups with taxpayers. Descriptive content analysis with an inductive approach. Results Across 10 interviews and four focus groups (n = 4–10 per group), there was varying knowledge of PC. Gaps in interview and focus group participants' knowledge related to knowing the services available in PC, how PC is paid for, how to initiate PC, and how PC affects the patient's relationship with existing providers. Regarding the model, negative feedback from interview participants included not having PC explained adequately and PC providers seen as consultants and not as full-time providers. Focus group participants indicated that the model sounded promising but noted the likely difficulty in enacting it in our current health care system. Positive feedback from interview participants included the perception that clinicians spent more time and provided more support for patients and families and the developing ability of PC services to provide care more broadly than at the very end of life. Focus group participants had similar observations related to perceived attention to care and broader application of PC. Perceptions of time-constrained care delivery and suboptimal provider-patient communication persist for some patients getting PC services. Conclusion Education for patients, caregivers, and community members about the roles and benefits of PC will be needed to successfully expand community-based PC.}, keywords = {}, pubstate = {published}, tppubtype = {article} } Context Palliative care (PC) model delivered by two large hospices and PC providers. Objectives To understand study participants' knowledge of PC and acceptability of a new community-based PC model. Methods Semistructured interview with patients and caregivers; focus groups with taxpayers. Descriptive content analysis with an inductive approach. Results Across 10 interviews and four focus groups (n = 4–10 per group), there was varying knowledge of PC. Gaps in interview and focus group participants' knowledge related to knowing the services available in PC, how PC is paid for, how to initiate PC, and how PC affects the patient's relationship with existing providers. Regarding the model, negative feedback from interview participants included not having PC explained adequately and PC providers seen as consultants and not as full-time providers. Focus group participants indicated that the model sounded promising but noted the likely difficulty in enacting it in our current health care system. Positive feedback from interview participants included the perception that clinicians spent more time and provided more support for patients and families and the developing ability of PC services to provide care more broadly than at the very end of life. Focus group participants had similar observations related to perceived attention to care and broader application of PC. Perceptions of time-constrained care delivery and suboptimal provider-patient communication persist for some patients getting PC services. Conclusion Education for patients, caregivers, and community members about the roles and benefits of PC will be needed to successfully expand community-based PC. |
Vassy, Jason L; Davis, Kelly J; Kirby, Christine; Richardson, Ian J; Green, Robert C; McGuire, Amy L; Ubel, Peter A How primary care providers talk to patients about genome sequencing results: Risk, rationale, and recommendation Journal Article Journal of General Internal Medicine, 33 (6), pp. 877-885, 2018. @article{Vassy2018, title = {How primary care providers talk to patients about genome sequencing results: Risk, rationale, and recommendation}, author = {Jason L Vassy and Kelly J Davis and Christine Kirby and Ian J Richardson and Robert C Green and Amy L McGuire and Peter A Ubel}, url = {https://link.springer.com/article/10.1007/s11606-017-4295-4}, year = {2018}, date = {2018-06-01}, journal = {Journal of General Internal Medicine}, volume = {33}, number = {6}, pages = {877-885}, abstract = {Background Genomics will play an increasingly prominent role in clinical medicine. Objective To describe how primary care physicians (PCPs) discuss and make clinical recommendations about genome sequencing results. Design Qualitative analysis. Participants PCPs and their generally healthy patients undergoing genome sequencing. Approach Patients received clinical genome reports that included four categories of results: monogenic disease risk variants (if present), carrier status, five pharmacogenetics results, and polygenic risk estimates for eight cardiometabolic traits. Patients’ office visits with their PCPs were audio-recorded, and summative content analysis was used to describe how PCPs discussed genomic results. Key Results For each genomic result discussed in 48 PCP–patient visits, we identified a “take-home” message (recommendation), categorized as continuing current management, further treatment, further evaluation, behavior change, remembering for future care, or sharing with family members. We analyzed how PCPs came to each recommendation by identifying 1) how they described the risk or importance of the given result and 2) the rationale they gave for translating that risk into a specific recommendation. Quantitative analysis showed that continuing current management was the most commonly coded recommendation across results overall (492/749, 66%) and for each individual result type except monogenic disease risk results. Pharmacogenetics was the most common result type to prompt a recommendation to remember for future care (94/119, 79%); carrier status was the most common type prompting a recommendation to share with family members (45/54, 83%); and polygenic results were the most common type prompting a behavior change recommendation (55/58, 95%). One-fifth of recommendation codes associated with monogenic results were for further evaluation (6/24, 25%). Rationales for these recommendations included patient context, family context, and scientific/clinical limitations of sequencing. Conclusions PCPs distinguish substantive differences among categories of genome sequencing results and use clinical judgment to justify continuing current management in generally healthy patients with genomic results.}, keywords = {}, pubstate = {published}, tppubtype = {article} } Background Genomics will play an increasingly prominent role in clinical medicine. Objective To describe how primary care physicians (PCPs) discuss and make clinical recommendations about genome sequencing results. Design Qualitative analysis. Participants PCPs and their generally healthy patients undergoing genome sequencing. Approach Patients received clinical genome reports that included four categories of results: monogenic disease risk variants (if present), carrier status, five pharmacogenetics results, and polygenic risk estimates for eight cardiometabolic traits. Patients’ office visits with their PCPs were audio-recorded, and summative content analysis was used to describe how PCPs discussed genomic results. Key Results For each genomic result discussed in 48 PCP–patient visits, we identified a “take-home” message (recommendation), categorized as continuing current management, further treatment, further evaluation, behavior change, remembering for future care, or sharing with family members. We analyzed how PCPs came to each recommendation by identifying 1) how they described the risk or importance of the given result and 2) the rationale they gave for translating that risk into a specific recommendation. Quantitative analysis showed that continuing current management was the most commonly coded recommendation across results overall (492/749, 66%) and for each individual result type except monogenic disease risk results. Pharmacogenetics was the most common result type to prompt a recommendation to remember for future care (94/119, 79%); carrier status was the most common type prompting a recommendation to share with family members (45/54, 83%); and polygenic results were the most common type prompting a behavior change recommendation (55/58, 95%). One-fifth of recommendation codes associated with monogenic results were for further evaluation (6/24, 25%). Rationales for these recommendations included patient context, family context, and scientific/clinical limitations of sequencing. Conclusions PCPs distinguish substantive differences among categories of genome sequencing results and use clinical judgment to justify continuing current management in generally healthy patients with genomic results. |
Arora, Nonie S; Davis, Kelly J; Kirby, Christine; McGuire, Amy L; Green, Robert C; Blumenthal-Barby, J S; Ubel, Peter A Communication challenges for non geneticist physicians relaying clinical genomic results Journal Article Personalized Medicine, 14 (5), pp. 423-431, 2017. @article{Arora2017, title = {Communication challenges for non geneticist physicians relaying clinical genomic results}, author = {Nonie S Arora and Kelly J Davis and Christine Kirby and Amy L McGuire and Robert C Green and J S Blumenthal-Barby and Peter A Ubel}, url = {https://www.futuremedicine.com/doi/abs/10.2217/pme-2017-0008}, year = {2017}, date = {2017-09-15}, journal = {Personalized Medicine}, volume = {14}, number = {5}, pages = {423-431}, abstract = {Aim: Identify the behavioral challenges to the use of genome sequencing (GS) in a clinical setting. Materials & methods: We observed how general internists and nongenetic specialists delivered GS results to patients enrolled in the MedSeq Project. Using transcripts of such disclosure interactions, we made qualitative observations of communication behaviors that could limit the usefulness of GS results until reaching the point of thematic saturation. Results: Findings included confusion regarding genomic terminology, difficulty with the volume or complexity of information and difficulties communicating complex risk information to patients. We observed a broad dismissal of clinical value of GS by some physicians and sometimes ineffective communication regarding health behavior change. Conclusion: Overcoming these behavioral challenges is necessary to make full use of clinical GS results.}, keywords = {}, pubstate = {published}, tppubtype = {article} } Aim: Identify the behavioral challenges to the use of genome sequencing (GS) in a clinical setting. Materials & methods: We observed how general internists and nongenetic specialists delivered GS results to patients enrolled in the MedSeq Project. Using transcripts of such disclosure interactions, we made qualitative observations of communication behaviors that could limit the usefulness of GS results until reaching the point of thematic saturation. Results: Findings included confusion regarding genomic terminology, difficulty with the volume or complexity of information and difficulties communicating complex risk information to patients. We observed a broad dismissal of clinical value of GS by some physicians and sometimes ineffective communication regarding health behavior change. Conclusion: Overcoming these behavioral challenges is necessary to make full use of clinical GS results. |
Hunter, Wynn G; Zafar, Yousuf S; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Barnett, Jamison A; Ubel, Peter A Discussing health care expenses in the oncology clinic: Analysis of cost conversations in outpatient encounters Journal Article Journal of Oncology Practice, 12 (11), pp. e944-e956, 2017. @article{Hunter2017, title = {Discussing health care expenses in the oncology clinic: Analysis of cost conversations in outpatient encounters}, author = {Wynn G Hunter and Yousuf S Zafar and Ashley Hesson and Kelly J Davis and Christine Kirby and Jamison A Barnett and Peter A Ubel}, url = {http://ascopubs.org/doi/abs/10.1200/JOP.2017.022855}, year = {2017}, date = {2017-08-23}, journal = {Journal of Oncology Practice}, volume = {12}, number = {11}, pages = {e944-e956}, abstract = {Purpose: ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits. Methods: We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013. Results: Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Purpose: ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits. Methods: We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013. Results: Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients … |
Brown, Gregory D; Hunter, Wynn G; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Barnett, Jamison A; Byelmac, Dmytro; Ubel, Peter A Discussing out-of-pocket expenses during clinical appointments: An observational study of patient-psychiatrist interactions Journal Article Psychiatric Services, 68 (6), pp. 610-617, 2017. @article{Brown2017, title = {Discussing out-of-pocket expenses during clinical appointments: An observational study of patient-psychiatrist interactions}, author = {Gregory D Brown and Wynn G Hunter and Ashley Hesson and Kelly J Davis and Christine Kirby and Jamison A Barnett and Dmytro Byelmac and Peter A Ubel}, url = {https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201600275}, year = {2017}, date = {2017-05-19}, journal = {Psychiatric Services}, volume = {68}, number = {6}, pages = {610-617}, abstract = {Objective: High out-of-pocket expenses for medical treatment have been associated with worse quality of life, decreased treatment adherence, and increased risk of adverse health outcomes. Treatment of depression potentially has high out-of-pocket expenses. Limited data characterize psychiatrist-patient conversations about health care costs. Methods: The authors conducted content analysis from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in community-based private practices nationwide from 2010 to 2014. Results: Patients’ health care expenses were discussed in 38% of clinic visits (95% confidence interval [CI]= 33%–43%). Uninsured patients were significantly more likely to discuss expenses than were patients enrolled in private or public plans (64%, 44%, and 30%, respectively; p<.001). Sixty-nine percent of cost conversations lasted less than one minute …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Objective: High out-of-pocket expenses for medical treatment have been associated with worse quality of life, decreased treatment adherence, and increased risk of adverse health outcomes. Treatment of depression potentially has high out-of-pocket expenses. Limited data characterize psychiatrist-patient conversations about health care costs. Methods: The authors conducted content analysis from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in community-based private practices nationwide from 2010 to 2014. Results: Patients’ health care expenses were discussed in 38% of clinic visits (95% confidence interval [CI]= 33%–43%). Uninsured patients were significantly more likely to discuss expenses than were patients enrolled in private or public plans (64%, 44%, and 30%, respectively; p<.001). Sixty-nine percent of cost conversations lasted less than one minute … |
Hunter, Wynn G; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Williamson, Lillie D; Barnett, Jamison A; Ubel, Peter A Patient-physician discussions about costs: Definitions and impact on cost conversation incidence estimates Journal Article BMC Health Services Research, 16 (1), pp. 108, 2016. @article{Hunter2016b, title = {Patient-physician discussions about costs: Definitions and impact on cost conversation incidence estimates}, author = {Wynn G Hunter and Ashley Hesson and Kelly J Davis and Christine Kirby and Lillie D Williamson and Jamison A Barnett and Peter A Ubel}, url = {https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1353-2}, year = {2016}, date = {2016-12-01}, journal = {BMC Health Services Research}, volume = {16}, number = {1}, pages = {108}, abstract = {Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests. Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests. Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost … |
Hunter, Wynn G; Zhang, Cecilia Z; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Williamson, Lillie D; Barnett, Jamison A; Ubel, Peter A Medical Decision Making, 36 (7), pp. 900-910, 2016. @article{Hunter2016b, title = {What strategies do physicians and patients discuss to reduce out-of-pocket costs? Analysis of cost-saving strategies in 1,755 outpatient clinic visits}, author = {Wynn G Hunter and Cecilia Z Zhang and Ashley Hesson and Kelly J Davis and Christine Kirby and Lillie D Williamson and Jamison A Barnett and Peter A Ubel}, url = {http://journals.sagepub.com/doi/10.1177/0272989X15626384}, doi = {10.1177/0272989X15626384}, year = {2016}, date = {2016-10-01}, journal = {Medical Decision Making}, volume = {36}, number = {7}, pages = {900-910}, abstract = {Background. More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. Objective. We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. Design. Retrospective analysis of dialogue from 1,755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. Results. Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Background. More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. Objective. We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. Design. Retrospective analysis of dialogue from 1,755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. Results. Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median … |
2018 |
Boucher, Nathan A; Bull, Janet H; Cross, Sarah H; Kirby, Christine; Davis, Kelly J; Jr., Donald Taylor H Patient, caregiver and taxpayer knowledge of palliative care and views on a model of community-based palliative care Journal Article Journal of Pain and Symptom Management, 2018. @article{Boucher2018, title = {Patient, caregiver and taxpayer knowledge of palliative care and views on a model of community-based palliative care}, author = {Nathan A Boucher and Janet H Bull and Sarah H Cross and Christine Kirby and Kelly J Davis and Donald Taylor H Jr.}, url = {https://www.sciencedirect.com/science/article/pii/S0885392418304378}, year = {2018}, date = {2018-08-25}, journal = {Journal of Pain and Symptom Management}, abstract = {Context Palliative care (PC) model delivered by two large hospices and PC providers. Objectives To understand study participants' knowledge of PC and acceptability of a new community-based PC model. Methods Semistructured interview with patients and caregivers; focus groups with taxpayers. Descriptive content analysis with an inductive approach. Results Across 10 interviews and four focus groups (n = 4–10 per group), there was varying knowledge of PC. Gaps in interview and focus group participants' knowledge related to knowing the services available in PC, how PC is paid for, how to initiate PC, and how PC affects the patient's relationship with existing providers. Regarding the model, negative feedback from interview participants included not having PC explained adequately and PC providers seen as consultants and not as full-time providers. Focus group participants indicated that the model sounded promising but noted the likely difficulty in enacting it in our current health care system. Positive feedback from interview participants included the perception that clinicians spent more time and provided more support for patients and families and the developing ability of PC services to provide care more broadly than at the very end of life. Focus group participants had similar observations related to perceived attention to care and broader application of PC. Perceptions of time-constrained care delivery and suboptimal provider-patient communication persist for some patients getting PC services. Conclusion Education for patients, caregivers, and community members about the roles and benefits of PC will be needed to successfully expand community-based PC.}, keywords = {}, pubstate = {published}, tppubtype = {article} } Context Palliative care (PC) model delivered by two large hospices and PC providers. Objectives To understand study participants' knowledge of PC and acceptability of a new community-based PC model. Methods Semistructured interview with patients and caregivers; focus groups with taxpayers. Descriptive content analysis with an inductive approach. Results Across 10 interviews and four focus groups (n = 4–10 per group), there was varying knowledge of PC. Gaps in interview and focus group participants' knowledge related to knowing the services available in PC, how PC is paid for, how to initiate PC, and how PC affects the patient's relationship with existing providers. Regarding the model, negative feedback from interview participants included not having PC explained adequately and PC providers seen as consultants and not as full-time providers. Focus group participants indicated that the model sounded promising but noted the likely difficulty in enacting it in our current health care system. Positive feedback from interview participants included the perception that clinicians spent more time and provided more support for patients and families and the developing ability of PC services to provide care more broadly than at the very end of life. Focus group participants had similar observations related to perceived attention to care and broader application of PC. Perceptions of time-constrained care delivery and suboptimal provider-patient communication persist for some patients getting PC services. Conclusion Education for patients, caregivers, and community members about the roles and benefits of PC will be needed to successfully expand community-based PC. |
Vassy, Jason L; Davis, Kelly J; Kirby, Christine; Richardson, Ian J; Green, Robert C; McGuire, Amy L; Ubel, Peter A How primary care providers talk to patients about genome sequencing results: Risk, rationale, and recommendation Journal Article Journal of General Internal Medicine, 33 (6), pp. 877-885, 2018. @article{Vassy2018, title = {How primary care providers talk to patients about genome sequencing results: Risk, rationale, and recommendation}, author = {Jason L Vassy and Kelly J Davis and Christine Kirby and Ian J Richardson and Robert C Green and Amy L McGuire and Peter A Ubel}, url = {https://link.springer.com/article/10.1007/s11606-017-4295-4}, year = {2018}, date = {2018-06-01}, journal = {Journal of General Internal Medicine}, volume = {33}, number = {6}, pages = {877-885}, abstract = {Background Genomics will play an increasingly prominent role in clinical medicine. Objective To describe how primary care physicians (PCPs) discuss and make clinical recommendations about genome sequencing results. Design Qualitative analysis. Participants PCPs and their generally healthy patients undergoing genome sequencing. Approach Patients received clinical genome reports that included four categories of results: monogenic disease risk variants (if present), carrier status, five pharmacogenetics results, and polygenic risk estimates for eight cardiometabolic traits. Patients’ office visits with their PCPs were audio-recorded, and summative content analysis was used to describe how PCPs discussed genomic results. Key Results For each genomic result discussed in 48 PCP–patient visits, we identified a “take-home” message (recommendation), categorized as continuing current management, further treatment, further evaluation, behavior change, remembering for future care, or sharing with family members. We analyzed how PCPs came to each recommendation by identifying 1) how they described the risk or importance of the given result and 2) the rationale they gave for translating that risk into a specific recommendation. Quantitative analysis showed that continuing current management was the most commonly coded recommendation across results overall (492/749, 66%) and for each individual result type except monogenic disease risk results. Pharmacogenetics was the most common result type to prompt a recommendation to remember for future care (94/119, 79%); carrier status was the most common type prompting a recommendation to share with family members (45/54, 83%); and polygenic results were the most common type prompting a behavior change recommendation (55/58, 95%). One-fifth of recommendation codes associated with monogenic results were for further evaluation (6/24, 25%). Rationales for these recommendations included patient context, family context, and scientific/clinical limitations of sequencing. Conclusions PCPs distinguish substantive differences among categories of genome sequencing results and use clinical judgment to justify continuing current management in generally healthy patients with genomic results.}, keywords = {}, pubstate = {published}, tppubtype = {article} } Background Genomics will play an increasingly prominent role in clinical medicine. Objective To describe how primary care physicians (PCPs) discuss and make clinical recommendations about genome sequencing results. Design Qualitative analysis. Participants PCPs and their generally healthy patients undergoing genome sequencing. Approach Patients received clinical genome reports that included four categories of results: monogenic disease risk variants (if present), carrier status, five pharmacogenetics results, and polygenic risk estimates for eight cardiometabolic traits. Patients’ office visits with their PCPs were audio-recorded, and summative content analysis was used to describe how PCPs discussed genomic results. Key Results For each genomic result discussed in 48 PCP–patient visits, we identified a “take-home” message (recommendation), categorized as continuing current management, further treatment, further evaluation, behavior change, remembering for future care, or sharing with family members. We analyzed how PCPs came to each recommendation by identifying 1) how they described the risk or importance of the given result and 2) the rationale they gave for translating that risk into a specific recommendation. Quantitative analysis showed that continuing current management was the most commonly coded recommendation across results overall (492/749, 66%) and for each individual result type except monogenic disease risk results. Pharmacogenetics was the most common result type to prompt a recommendation to remember for future care (94/119, 79%); carrier status was the most common type prompting a recommendation to share with family members (45/54, 83%); and polygenic results were the most common type prompting a behavior change recommendation (55/58, 95%). One-fifth of recommendation codes associated with monogenic results were for further evaluation (6/24, 25%). Rationales for these recommendations included patient context, family context, and scientific/clinical limitations of sequencing. Conclusions PCPs distinguish substantive differences among categories of genome sequencing results and use clinical judgment to justify continuing current management in generally healthy patients with genomic results. |
2017 |
Arora, Nonie S; Davis, Kelly J; Kirby, Christine; McGuire, Amy L; Green, Robert C; Blumenthal-Barby, J S; Ubel, Peter A Communication challenges for non geneticist physicians relaying clinical genomic results Journal Article Personalized Medicine, 14 (5), pp. 423-431, 2017. @article{Arora2017, title = {Communication challenges for non geneticist physicians relaying clinical genomic results}, author = {Nonie S Arora and Kelly J Davis and Christine Kirby and Amy L McGuire and Robert C Green and J S Blumenthal-Barby and Peter A Ubel}, url = {https://www.futuremedicine.com/doi/abs/10.2217/pme-2017-0008}, year = {2017}, date = {2017-09-15}, journal = {Personalized Medicine}, volume = {14}, number = {5}, pages = {423-431}, abstract = {Aim: Identify the behavioral challenges to the use of genome sequencing (GS) in a clinical setting. Materials & methods: We observed how general internists and nongenetic specialists delivered GS results to patients enrolled in the MedSeq Project. Using transcripts of such disclosure interactions, we made qualitative observations of communication behaviors that could limit the usefulness of GS results until reaching the point of thematic saturation. Results: Findings included confusion regarding genomic terminology, difficulty with the volume or complexity of information and difficulties communicating complex risk information to patients. We observed a broad dismissal of clinical value of GS by some physicians and sometimes ineffective communication regarding health behavior change. Conclusion: Overcoming these behavioral challenges is necessary to make full use of clinical GS results.}, keywords = {}, pubstate = {published}, tppubtype = {article} } Aim: Identify the behavioral challenges to the use of genome sequencing (GS) in a clinical setting. Materials & methods: We observed how general internists and nongenetic specialists delivered GS results to patients enrolled in the MedSeq Project. Using transcripts of such disclosure interactions, we made qualitative observations of communication behaviors that could limit the usefulness of GS results until reaching the point of thematic saturation. Results: Findings included confusion regarding genomic terminology, difficulty with the volume or complexity of information and difficulties communicating complex risk information to patients. We observed a broad dismissal of clinical value of GS by some physicians and sometimes ineffective communication regarding health behavior change. Conclusion: Overcoming these behavioral challenges is necessary to make full use of clinical GS results. |
Hunter, Wynn G; Zafar, Yousuf S; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Barnett, Jamison A; Ubel, Peter A Discussing health care expenses in the oncology clinic: Analysis of cost conversations in outpatient encounters Journal Article Journal of Oncology Practice, 12 (11), pp. e944-e956, 2017. @article{Hunter2017, title = {Discussing health care expenses in the oncology clinic: Analysis of cost conversations in outpatient encounters}, author = {Wynn G Hunter and Yousuf S Zafar and Ashley Hesson and Kelly J Davis and Christine Kirby and Jamison A Barnett and Peter A Ubel}, url = {http://ascopubs.org/doi/abs/10.1200/JOP.2017.022855}, year = {2017}, date = {2017-08-23}, journal = {Journal of Oncology Practice}, volume = {12}, number = {11}, pages = {e944-e956}, abstract = {Purpose: ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits. Methods: We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013. Results: Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Purpose: ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits. Methods: We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013. Results: Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients … |
Brown, Gregory D; Hunter, Wynn G; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Barnett, Jamison A; Byelmac, Dmytro; Ubel, Peter A Discussing out-of-pocket expenses during clinical appointments: An observational study of patient-psychiatrist interactions Journal Article Psychiatric Services, 68 (6), pp. 610-617, 2017. @article{Brown2017, title = {Discussing out-of-pocket expenses during clinical appointments: An observational study of patient-psychiatrist interactions}, author = {Gregory D Brown and Wynn G Hunter and Ashley Hesson and Kelly J Davis and Christine Kirby and Jamison A Barnett and Dmytro Byelmac and Peter A Ubel}, url = {https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201600275}, year = {2017}, date = {2017-05-19}, journal = {Psychiatric Services}, volume = {68}, number = {6}, pages = {610-617}, abstract = {Objective: High out-of-pocket expenses for medical treatment have been associated with worse quality of life, decreased treatment adherence, and increased risk of adverse health outcomes. Treatment of depression potentially has high out-of-pocket expenses. Limited data characterize psychiatrist-patient conversations about health care costs. Methods: The authors conducted content analysis from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in community-based private practices nationwide from 2010 to 2014. Results: Patients’ health care expenses were discussed in 38% of clinic visits (95% confidence interval [CI]= 33%–43%). Uninsured patients were significantly more likely to discuss expenses than were patients enrolled in private or public plans (64%, 44%, and 30%, respectively; p<.001). Sixty-nine percent of cost conversations lasted less than one minute …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Objective: High out-of-pocket expenses for medical treatment have been associated with worse quality of life, decreased treatment adherence, and increased risk of adverse health outcomes. Treatment of depression potentially has high out-of-pocket expenses. Limited data characterize psychiatrist-patient conversations about health care costs. Methods: The authors conducted content analysis from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in community-based private practices nationwide from 2010 to 2014. Results: Patients’ health care expenses were discussed in 38% of clinic visits (95% confidence interval [CI]= 33%–43%). Uninsured patients were significantly more likely to discuss expenses than were patients enrolled in private or public plans (64%, 44%, and 30%, respectively; p<.001). Sixty-nine percent of cost conversations lasted less than one minute … |
2016 |
Hunter, Wynn G; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Williamson, Lillie D; Barnett, Jamison A; Ubel, Peter A Patient-physician discussions about costs: Definitions and impact on cost conversation incidence estimates Journal Article BMC Health Services Research, 16 (1), pp. 108, 2016. @article{Hunter2016b, title = {Patient-physician discussions about costs: Definitions and impact on cost conversation incidence estimates}, author = {Wynn G Hunter and Ashley Hesson and Kelly J Davis and Christine Kirby and Lillie D Williamson and Jamison A Barnett and Peter A Ubel}, url = {https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1353-2}, year = {2016}, date = {2016-12-01}, journal = {BMC Health Services Research}, volume = {16}, number = {1}, pages = {108}, abstract = {Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests. Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests. Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost … |
Hunter, Wynn G; Zhang, Cecilia Z; Hesson, Ashley; Davis, Kelly J; Kirby, Christine; Williamson, Lillie D; Barnett, Jamison A; Ubel, Peter A Medical Decision Making, 36 (7), pp. 900-910, 2016. @article{Hunter2016b, title = {What strategies do physicians and patients discuss to reduce out-of-pocket costs? Analysis of cost-saving strategies in 1,755 outpatient clinic visits}, author = {Wynn G Hunter and Cecilia Z Zhang and Ashley Hesson and Kelly J Davis and Christine Kirby and Lillie D Williamson and Jamison A Barnett and Peter A Ubel}, url = {http://journals.sagepub.com/doi/10.1177/0272989X15626384}, doi = {10.1177/0272989X15626384}, year = {2016}, date = {2016-10-01}, journal = {Medical Decision Making}, volume = {36}, number = {7}, pages = {900-910}, abstract = {Background. More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. Objective. We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. Design. Retrospective analysis of dialogue from 1,755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. Results. Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median …}, keywords = {}, pubstate = {published}, tppubtype = {article} } Background. More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. Objective. We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. Design. Retrospective analysis of dialogue from 1,755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. Results. Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median … |