Cost and Shared Decision-Making for Heart Failure

NCT ID: NCT04793880

Last Updated: 2023-12-15

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

247 participants

Study Classification

INTERVENTIONAL

Study Start Date

2021-06-01

Study Completion Date

2023-11-15

Brief Summary

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This study is designed to understand the impact of providing patient-specific cost at the time of the clinical encounter on decision-making for heart failure medications. The researchers will provide patients with heart failure with patient-specific cost information for non-generic heart failure medications. This cost information will be populated onto a checklist of recommended HF medications so that patients and their clinicians will have this information available during their clinical encounter. Patients in the control arm will receive the same checklist but without the cost information.

Detailed Description

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For many years, medical treatment of heart failure with reduced ejection fraction (HFrEF) was defined by a combination of low-cost, generic medications. Recently, new medications have demonstrated reductions in mortality and hospitalization. These include the angiotensin receptor blocker and neprilysin inhibitor (ARNI) sacubitril-valsartan, sodium-glucose cotransporter-2 inhibitors (SGLT2I), and ivabradine. These medications all carry important clinical benefits but also are more expensive, with co-payments varying significantly but often in the range of $50-$100 per month. These costs are highly relevant for patients' decisions, especially for patients who have Medicare Part D drug coverage and are not eligible for co-pay assistance programs.

Prior research has demonstrated that patients are sensitive to costs regarding HFrEF medications and receptive to cost discussions with clinicians. Some broad efforts at price transparency have been promoted, but generic price information is of little value to patients and clinicians when out-of-pocket costs vary significantly from patient to patient based on insurance coverage. At present, neither clinicians nor patients have out-of-pocket costs available at the time of clinical encounters in order to facilitate integration of this information into decisions.

The objective of this trial is to examine the impact of integrating patient-specific out-of-pocket cost into shared decision-making regarding heart failure medications in patients with HFrEF. This will be performed by integrating patient-specific cost into an existing, evidence-based checklist for HFrEF medications. The study will utilize a simple cluster-randomized design. All patients in the study will receive, at the time of a clinical encounter, an evidence-based heart failure medication checklist that describes guideline-recommended medications for HFrEF. Patients in the intervention group will receive a version of the checklist that also includes their estimated co-payment for non-generic heart failure medications based upon their insurance status at the time of the encounter.

This study is designed as a preliminary trial to understand the real impact of providing patient-specific cost at the time of the clinical encounter. The researchers will audio record clinical encounters, conduct a follow-up survey with participants, and collect follow-up data regarding each patient's medications.

Conditions

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Chronic Heart Failure

Keywords

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Out-of-pocket cost Shared decision-making Heart failure with reduced ejection fraction (HFrEF)

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

This study utilizes a stepped wedge cluster-randomized design where study sites are assigned to transition to the intervention as recruitment milestone are met.
Primary Study Purpose

HEALTH_SERVICES_RESEARCH

Blinding Strategy

NONE

Study Groups

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Medication checklist with cost information

Participants with chronic heart failure with reduced ejection fraction (HFrEF) having a clinic visit at a site randomized to the medication checklist with cost information intervention.

Group Type EXPERIMENTAL

Medication Cost Information

Intervention Type BEHAVIORAL

This version of the HFrEF medication checklist includes patient-specific estimated monthly out-of-pocket cost for each medication. TailorMed, a company designed to provide financial counseling and planning for patients, will generate the patients' out-of-pocket cost based on insurance status. The costs for non-generic HFrEF medications will then be populated onto a checklist of recommended heart failure medications so that patients and their clinicians will have this information available during their clinical encounter.

Heart Failure Medicines Checklist

Intervention Type BEHAVIORAL

The Heart Failure Medicines Checklist is an evidence-based medication checklist that describes guideline-recommended medications for HFrEF. This tool is used during the clinical encounter to facilitate a discussion about medications that may be most appropriate for the patient.

Medication checklist

Participants with chronic heart failure with reduced ejection fraction (HFrEF) having a clinic visit at a site randomized to the medication checklist without cost information.

Group Type ACTIVE_COMPARATOR

Heart Failure Medicines Checklist

Intervention Type BEHAVIORAL

The Heart Failure Medicines Checklist is an evidence-based medication checklist that describes guideline-recommended medications for HFrEF. This tool is used during the clinical encounter to facilitate a discussion about medications that may be most appropriate for the patient.

Interventions

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Medication Cost Information

This version of the HFrEF medication checklist includes patient-specific estimated monthly out-of-pocket cost for each medication. TailorMed, a company designed to provide financial counseling and planning for patients, will generate the patients' out-of-pocket cost based on insurance status. The costs for non-generic HFrEF medications will then be populated onto a checklist of recommended heart failure medications so that patients and their clinicians will have this information available during their clinical encounter.

Intervention Type BEHAVIORAL

Heart Failure Medicines Checklist

The Heart Failure Medicines Checklist is an evidence-based medication checklist that describes guideline-recommended medications for HFrEF. This tool is used during the clinical encounter to facilitate a discussion about medications that may be most appropriate for the patient.

Intervention Type BEHAVIORAL

Eligibility Criteria

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Inclusion Criteria

* Diagnosis of HFrEF (ejection fraction \< 40%)
* Outpatient clinical encounter with cardiologist (virtual or in-person)

Exclusion Criteria

* Advanced HF therapy (LVAD or transplant or undergoing active workup or listing for these therapies; home inotrope usage)
* Patient currently in hospice care or with known life expectancy under 1 year
* Dialysis-dependence or glomerular filtration rate (GFR) \< 30 (due to medication contraindications)
* Pregnancy (because many guideline-recommended drugs, including those with associated high costs, are not approved for use in pregnancy)
* Non-English speaking (because of the absence of non-English speaking research staff to communicate with non-English speaking patients and to qualitatively analyze/code audio-recorded data)
Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No

Sponsors

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Agency for Healthcare Research and Quality (AHRQ)

FED

Sponsor Role collaborator

Emory University

OTHER

Sponsor Role lead

Responsible Party

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Neal Dickert

Associate Professor

Responsibility Role PRINCIPAL_INVESTIGATOR

Principal Investigators

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Neal W Dickert, MD, PhD

Role: PRINCIPAL_INVESTIGATOR

Emory University

Locations

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UCHealth Heart and Vascular Center Clinics

Aurora, Colorado, United States

Site Status

Emory University Hospital Midtown

Atlanta, Georgia, United States

Site Status

Emory Clinic, Emory University Hospital

Atlanta, Georgia, United States

Site Status

Emory St. Joseph's Hospital

Atlanta, Georgia, United States

Site Status

Countries

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United States

References

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Dickert NW, Speight CD, Balser M, Biermann H, Davis JK, Halpern SD, Ko YA, Krishnan A, Matlock DD, Mitchell AR, Moore MA, Montembeau SC, Morris AA, Noonan K, Rao BR, Scherer LD, Sloan CE, Ubel PA, Allen LA. Integrating Out-of-Pocket Costs Into Shared Decision-Making for Heart Failure With Reduced Ejection Fraction: A Stepped-Wedge Trial (POCKET-COST-HF). Circ Cardiovasc Qual Outcomes. 2025 Jan;18(1):e011273. doi: 10.1161/CIRCOUTCOMES.124.011273. Epub 2024 Dec 3.

Reference Type DERIVED
PMID: 39624892 (View on PubMed)

Montembeau SC, Rao BR, Mitchell AR, Speight CD, Allen LA, Halpern SD, Ko YA, Matlock DD, Moore MA, Morris AA, Scherer LD, Ubel P, Dickert NW. Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF): A Trial Providing Out-of-Pocket Costs for Heart Failure Medications during Clinical Encounters. Am Heart J. 2024 Mar;269:84-93. doi: 10.1016/j.ahj.2023.11.013. Epub 2023 Dec 12.

Reference Type DERIVED
PMID: 38096946 (View on PubMed)

Provided Documents

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Document Type: Informed Consent Form

View Document

Other Identifiers

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1R01HS026081-01

Identifier Type: AHRQ

Identifier Source: secondary_id

View Link

STUDY00002215

Identifier Type: -

Identifier Source: org_study_id