Jennifer K. Carroll, MD, MPH; Subrina Farah, MS; Robert J. Fortuna, MD, MPH; Angela M. Lanigan, MPA, RD; Mechelle Sanders, BA; Jineane V. Venci, PharmD, MS-CI; Kevin Fiscella, MD, MPH
Acknowledgment: The authors thank the 7 practices that participated in this project and Kathleen Silver for assistance in preparing and submitting this manuscript.
Financial Support: By the Robert Wood Johnson Foundation (ID 74124).
Disclosures: Ms. Farah reports grants from the Robert Wood Johnson Foundation to her institution. Ms. Sanders reports a grant from the Robert Wood Johnson Foundation. Dr. Lanigan reports a grant from the Robert Wood Johnson Foundation. Dr. Fiscella reports a grant from the Robert Wood Johnson Foundation. Dr. Venci reports personal fees from Greater Rochester Health Home Network and PharmCon FreeCE outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2011.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Proctor & Gamble, Pfizer, and Johnson & Johnson. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Corresponding Author: Kevin Fiscella, MD, MPH, Departments of Family Medicine, Public Health Sciences, and Community Health, University of Rochester Medical Center, 1381 South Avenue, Rochester, NY 14620; e-mail, Kevin_Fiscella@urmc.rochester.edu.
Current Author Addresses: Dr. Carroll: Department of Family Medicine, University of Colorado, 12631 East 17th Avenue, Room 3417, Building A01, Mail Stop F496, Aurora, CO 80045.
Dr. Lanigan: National Research Network, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211.
Ms. Farah and Ms. Sanders: Department of Family Medicine, University of Rochester, 1381 South Avenue, Rochester, NY 14620.
Dr. Fortuna: Departments of Internal Medicine, Pediatrics, and Community Health and Center for Primary Care, University of Rochester, 913 Culver Road, Rochester, NY 14609.
Dr. Venci: Department of Primary Care, University of Rochester Medical Center, 135 Corporate Woods, Suite 241, Rochester, NY 14623.
Dr. Fiscella: Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, 1381 South Avenue, Rochester, NY 14620.
Author Contributions: Conception and design: J.K. Carroll, S. Farah, K. Fiscella.
Analysis and interpretation of the data: S. Farah, R.J. Fortuna, A.M. Lanigan, M. Sanders, K. Fiscella.
Drafting of the article: J.K. Carroll, S. Farah, R.J. Fortuna, A.M. Lanigan, M. Sanders, J.V. Venci, K. Fiscella.
Critical revision of the article for important intellectual content: J.K. Carroll, R.J. Fortuna, K. Fiscella.
Final approval of the article: J.K. Carroll, R.J. Fortuna, A.M. Lanigan, J.V. Venci, K. Fiscella.
Provision of study materials or patients: J.K. Carroll, R.J. Fortuna, J.V. Venci.
Statistical expertise: S. Farah.
Administrative, technical, or logistic support: J.K. Carroll.
Collection and assembly of data: J.K. Carroll, S. Farah, A.M. Lanigan, K. Fiscella.
Medications contribute to patients' out-of-pocket costs, yet most clinicians do not routinely screen for patients' cost-of-medication (COM) concerns.
To assess whether a single training session improves COM conversations.
Before–after cross-sectional surveys of patients and qualitative interviews with clinicians and staff.
7 primary care practices in 3 U.S. states.
In total, 700 patients were surveyed from May 2017 to January 2018: 50 patients per practice before the intervention and another 50 patients per practice after the intervention. Eligibility criteria included age 18 years or older and taking 1 or more long-term medications. Qualitative interviews with 45 staff members were conducted.
A single 60-minute training session for clinicians and staff from each practice on COM importance, team-based screening, and cost-saving strategies.
Patient data (demographics, number of long-term medications, total monthly out-of-pocket medication costs, and history of cost-related medication nonadherence) were obtained immediately before and 3 months after the intervention. Practice staff were interviewed 3 months after the intervention.
A total of 700 patient surveys were completed. Frequency of COM discussion improved in 6 of the 7 practices and remained unchanged in 1 practice. Overall, COM conversations with patients increased from 17% at baseline to 32% postintervention (P = 0.00). There was substantial heterogeneity among sites in before–after differences in patient-reported out-of-pocket COM. Qualitative analyses from key informant interviews showed wide variation in implementation of screening approaches, workflow, adoption of a team-based approach, and strategies for addressing COM.
It is not known whether improvements in COM conversations were sustained beyond 3 months.
A single team training to screen and address patients' medication cost concerns improved COM discussions over the short term. Further research is needed to assess sustained effects and impact on patient costs and medication adherence and to determine whether more intensive, scalable interventions are needed.
Robert Wood Johnson Foundation.
Table 1. Components of Primary Care Training for Addressing Patient Medication Costs
Table 2. Participant Characteristics Before and After the Intervention, by Site
Discussion of medication costs before and after the intervention, by site.
Median out-of-pocket costs before and after the intervention, by site.
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Carroll JK, Farah S, Fortuna RJ, et al. Addressing Medication Costs During Primary Care Visits: A Before–After Study of Team-Based Training. Ann Intern Med. 2019;170:S46–S53. doi: https://doi.org/10.7326/M18-2011
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Published: Ann Intern Med. 2019;170(9_Supplement):S46-S53.
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