title: Patient-physician discussions about costs: definitions and impact on cost conversation incidence estimates.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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/Coverage, Cost of Illness, respectively; P < 0.001); depression: 30, 38, 43%, (P < 0.001); and rheumatoid arthritis, 26, 33, 35%, (P < 0.001).
  
  
  CONCLUSIONS
  The estimated incidence of physician-patient cost conversation varied significantly depending on the definition used. Our findings and proposed definitions may assist in retrospective interpretation and prospective design of investigations on this topic.
authors.affiliation: Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA. wynn.hunter@duke.edu.
authors.forename: Wynn G
authors.initials: WG
authors.lastname: Hunter
authors.affiliation: Michigan State University, College of Human Medicine, East Lansing, MI, USA.
authors.forename: Ashley
authors.initials: A
authors.lastname: Hesson
authors.affiliation: Duke University, Fuqua School of Business, Durham, NC, USA.
authors.forename: J Kelly
authors.initials: JK
authors.lastname: Davis
authors.affiliation: Duke University, Fuqua School of Business, Durham, NC, USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Kirby
authors.affiliation: University of Illinois, Department of Communication, Champaign, IL, USA.
authors.forename: Lillie D
authors.initials: LD
authors.lastname: Williamson
authors.affiliation: Verilogue Incorporated, Horsham, PA, USA.
authors.forename: Jamison A
authors.initials: JA
authors.lastname: Barnett
authors.affiliation: Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA.|Duke University, Fuqua School of Business, Durham, NC, USA.|Duke University, Sanford School of Public Policy, Durham, NC, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Ubel
mesh_terms: D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid; D003142:Communication; D003365:Costs and Cost Analysis; D005260:Female; D005382:Financing, Personal / Q000191:economics*; D005102:Health Expenditures; D006801:Humans; D007388:Internal Medicine; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D011446:Prospective Studies; D012189:Retrospective Studies; D055815:Young Adult
keywords: Cost of illness; Health expenditures; Medical decision-making; Out-of-pocket costs; Patient-centered care; Patient-physician communication