Kim Erwin, MDes; Veronica Fitzpatrick, DrPH; Sarah Norell, MDes, MFA; Melissa Gilliam, MD
Acknowledgment: The authors gratefully acknowledge the help of Tomoko Ichikawa, IIT Institute of Design; Jenny Sculley, University of Illinois at Chicago; Amanda Geppert, University of Chicago; and graduate students at the IIT Institute of Design for their assistance with project development: Darshana Nair, Jennifer L. Peterson, Renee Albrecht-Mallinger, Archana Belani, and Sonia Lala.
Financial Support: By the Robert Wood Johnson Foundation (grant 74126) under the funding mechanism Can We Talk?
Disclosures: Ms. Erwin reports grants from the Robert Wood Johnson Foundation during the conduct of the study. Ms. Norell reports grants from the Robert Wood Johnson Foundation during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2207.
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: Kim Erwin, MDes, University of Illinois at Chicago, 1220 South Wood Street, Third Floor, Chicago, IL 60608; e-mail, firstname.lastname@example.org.
Current Author Addresses: Ms. Erwin and Ms. Norell: University of Illinois at Chicago, 1220 South Wood Street, Third Floor, Chicago, IL 60608.
Dr. Fitzpatrick: Sinai Urban Health Institute, 1500 South Fairfield Avenue, K448, Chicago, IL 60608.
Dr. Gilliam: The University of Chicago, 5801 South Ellis Avenue, Chicago, IL 60637.
Author Contributions: Conception and design: K. Erwin, V. Fitzpatrick, S. Norell, M. Gilliam.
Analysis and interpretation of the data: K. Erwin, V. Fitzpatrick, S. Norell, M. Gilliam.
Drafting of the article: K. Erwin, V. Fitzpatrick, S. Norell, M. Gilliam.
Critical revision of the article for important intellectual content: K. Erwin, S. Norell, M. Gilliam.
Final approval of the article: K. Erwin, V. Fitzpatrick, S. Norell, M. Gilliam.
Provision of study materials or patients: K. Erwin, M. Gilliam.
Obtaining of funding: K. Erwin, V. Fitzpatrick, M. Gilliam.
Administrative, technical, or logistic support: V. Fitzpatrick, S. Norell, M. Gilliam.
Collection and assembly of data: K. Erwin, S. Norell.
Studies show that patients want to engage in cost-of-care conversations and factor costs into the formulation of care plans. Low-income patients are particularly likely to defer care because of costs, suggesting that cost-of-care conversations may be an important factor in health equity. Little guidance is available to clinicians and health systems for how to integrate effective cost-of-care conversations into clinical practice or to address specific cost needs of low-income patients.
To develop a framework and tool to assist cost-of-care conversations with low-income patients during prenatal care.
A qualitative study using human-centered design methods.
University medical center–based obstetrics-gynecology (ob-gyn) practice.
20 pregnant or recently postpartum women, 16 clinicians, and 8 support and executive staff.
Pregnant women accumulate substantial indirect costs that interfere with treatment adherence and stress patients and their relationships. Frequency and duration of appointments are primary drivers of indirect costs; the burden is exacerbated by not knowing these costs in advance and disproportionately affects low-income patients. Working with ob-gyn clinicians, staff, and patients, a paper-based tool was developed to help patients forecast treatment demands and indirect costs, and to help clinicians introduce and standardize cost conversations.
Data were collected from a small number of stakeholders in a single clinical setting that may not be generalizable to other settings. The tool has not been tested for effects on adherence or clinical outcomes.
A communication tool that helps pregnant patients understand their care plan and anticipate indirect costs can promote cost-of-care conversations between clinicians and low-income patients.
Robert Wood Johnson Foundation.
Overview of the 5-step development process.
lit = literature; MA = medical assistant; ob-gyn = obstetrician-gynecologist.
Table. Stakeholder Requirements of Cost-of-Care Conversations
Final cost conversation support tool that features a checkbox format that fits both low- and high-risk pregnancy care (1); descriptions of tests and procedures, including estimated times and preparation tips (2); a timeline for all appointments (3); a planning worksheet on the back page, away from the treatment section, orienting patients to indirect costs (4); insurance and treatment questions to help patients initiate cost conversations with clinicians and payers (5); and support phone numbers for services on the front cover (6).
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Erwin K, Fitzpatrick V, Norell S, Gilliam M. Development of a Framework and Tool to Facilitate Cost-of-Care Conversations With Patients During Prenatal Care. Ann Intern Med. 2019;170:S62–S69. doi: 10.7326/M18-2207
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Published: Ann Intern Med. 2019;170(9_Supplement):S62-S69.
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