Abstract
Background:
Rural family caregivers (FCGs) in the United States often experience high economic costs. This randomized controlled trial compared a transitional palliative care intervention (TPC) to support FCGs of seriously ill care recipients (CRs) to an attention control condition. We evaluated the TPC’s effect on healthcare use and out-of-pocket spending for both FCGs and CRs.
Methods:
TPC FCGs received teaching, guidance, and counseling via video calls for 8 weeks following CR discharge from the hospital. After discharge, a research assistant called all FCGs once a month for up to 6 months or CR death to collect self-reported healthcare utilization (e.g., outpatient, emergency department, and hospital), out-of-pocket healthcare spending (e.g., deductibles and coinsurance), and health-related travel costs (e.g., transportation, lodging, food) for FCGs and CRs. Incidence rate ratios (IRRs) were estimated using negative binomial regressions.
Results:
The study included 282 FCG–CR dyads across three U.S. states. Follow-up over the 6-month period was shortened by high CR mortality rates across both arms (29%), but was similar across arms. TPC reduced nights in the hospital for CR (IRR = 0.75; 95% confidence interval [CI] = 0.56–0. 99). Total out-of-pocket spending was not significantly different for TPC versus control. Across both groups, mean out-of-pocket spending for dyads was $1401.85, with healthcare payments contributing $1048.58 and transportation expenses contributing $136.79. TPC dyads reported lower lodging costs (IRR = 0.71; 95% CI = 0.56–0.89).
Conclusions:
This study contributes to evidence that palliative care interventions reduce the number of nights in the hospital for seriously ill patients. Yet, overall rural FCGs and seriously ill CRs experience substantial out-of-pocket economic costs in the 6 months following hospitalization. Transitional care intervention design should consider impacts on patient and caregiver spending. ClinicalTrials.gov # is NCT03339271.
Keywords: end-of-life, family caregiver, healthcare cost, palliative care, randomized controlled trial
INTRODUCTION
One in five U.S. adults aged 45 years or older reported acting in a caregiving role in the past 30 days in a nationally representative survey.1 Family caregivers (FCGs) continue to play a critical, yet under-recognized role in the transition from hospital to home. The caregiver role during transitions of care is multifaceted: facilitating conversations between providers and patients, maintaining medical records, advocating for patients, and executing new physical caregiving tasks.1–3 Rural FCGs in the United States often experience substantial economic costs for healthcare and caregiver activities, in addition to physical and emotional strain. However, the effects of transitional care models on health services use and out-of-pocket spending for FCG are not well understood.
Rural FCGs compared with non-rural FCGs face additional challenges when caring for loved ones. Fewer support services and opportunities to access healthcare services exist in rural areas, which leads to greater demand on FCG to provide that care. Rural communities generally experience greater geographic distance from care, lower access to specialists, and lower levels of education and income, all of which may complicate the responsibilities associated with caregiving.3–6 Obtaining paid care in the home is also more difficult in rural areas, due to workforce shortages and lack of community-based home health services, thus rural FCGs often operate without complementary care.7 Despite these additional challenges, some studies do not show significant differences in caregiving burden between urban and rural caregivers.8,9 For example, many rural caregivers report having a strong network of social support at home, which extended trips to urban medical centers can disrupt.10 However, it is also possible that differences in cultural norms between rural and urban areas may contribute to an underreporting of challenges and psychosocial strain associated with caregiving among rural residents.4,11 In particular, studies suggest that rural caregivers may face greater financial impacts due to caregiving roles than their urban counterparts.4
Evidence evaluating telehealth transitional care for FCGs is increasing12–14; a 2022 review found three out of four studies reported reduced FCG burden.15 However, most studies limit recruitment to FCGs of CR with a particular diagnosis (e.g., heart failure,16,17 cancer18,19). More evidence is needed on the efficacy of telehealth interventions during care transitions, particularly among rural-dwelling FCGs and CRs, and their impact on financial outcomes, such as out-of-pocket costs.4,20 This study is novel due to the focus on rural FCG needs in a broad, serious illness population.
The multi-site randomized controlled trial compared outcomes of a transitional palliative care intervention (TPC) to support FCGs in rural and medically underserved areas for seriously ill care recipients (CRs) to an attention control condition. The three primary outcomes in the trial included caregiving skills (e.g., caregiving preparedness, communication with clinicians, and satisfaction with care), FCG health outcomes (e.g., quality of life, burden, coping skills, depression), and healthcare use and out-of-pocket costs associated with caregiving. The objective of this article is to evaluate the effect of the TPC intervention on CR and FCG healthcare use and combined out-of-pocket spending. We hypothesized that the intervention would reduce healthcare utilization and spending for both CRs and FCGs over 6 months following CR hospital discharge.
METHODS
This study evaluated healthcare use and cost data from a randomized control trial that evaluated the effects of TPC on FCG and CR outcomes.21 Community-dwelling rural FCGs of hospitalized patients with a serious life-limiting illness and receiving palliative care during hospitalization were randomized 1:1 into an intervention or attention control group.22 CRs were determined to be seriously ill if they received inpatient palliative care consultation during their hospitalization. FCG and CR were recruited from one of 5 hospitals and lived in Minnesota, Iowa, or Wisconsin. This study and informed consent procedures were approved by the respective institutional review boards.
The TPC intervention provided teaching, guidance, and counseling for the FCG. In the intervention arm, FCGs received counseling via video calls for 8 weeks following CR’s discharge from the hospital. During these calls, a palliative care nurse would guide participants through an individualized plan of care designed to improve FCGs’ caregiving skills while also addressing FCGs’ personal health needs. The nurse and family FCG conducted at least one video visit within 24–48 h after hospital discharge, followed by two weekly visits in the first month and one weekly visit in the second month post-discharge. A research assistant assessed study outcomes via telephone monthly for 6 months or time of death post-index hospitalization. The study coordinator called FCGs once a month for 6 months or until CR death to collect self-reported healthcare-related cost and health services utilization data. After the censoring date (earliest of the withdrawal date, end of the study period, or the death date), the study coordinator contacted the FCG to complete a final cost survey. Respondents were instructed to report health services and costs that were incurred up until the end of the study (date of death). The days between the date of censoring and the cost survey completion were not included in the calculation of rates.
Participant inclusion
In the trial, 429 participants met inclusion criteria and were randomized 1:1 to intervention or attention control arm. Cost analyses included all participants who completed at least one cost survey (Supplemental Material Figure S1). Cost data were unavailable for 107 participants because the CR died prior to discharge or did not receive allocated intervention or attention control. Among participants randomized to intervention (n = 168) or control (n = 154), the completion of cost reports was 85% in the control arm and 89% in the intervention arm; this difference was not statistically significant (p > 0.05).
Outcome measures
Data were collected from 2018 to 2022. Trained research staff used the Ambulatory and Home Care Record (AHCR) to gather self-reported cost data over the phone. The AHCR has been validated for CR and FCG dyads to document self-reported utilization, and monetary costs, including healthcare costs for services used by FCG and CR (e.g., home healthcare, doctor appointments, emergency department visits, hospitalizations), costs related to receiving healthcare services (e.g., transportation, lodging, food), supply costs (e.g., medication and equipment), and time spent by FCG providing care.23 Monthly calls were intended to minimize recall bias and the extended 6 month period allowed for costs to be reported even when there was a lag in billing systems.21
For each section of the AHCR that records utilization, we aggregated the total number of events for the FCG and the CR for each type of event. Due to the low number of events and sample size, we did not have power to evaluate the individual types of services reported. For each section of the AHCR that records monetary cost, we analyzed participant total out-of-pocket healthcare payments, transportation expenses, lodging expenses, food expenses, and expenses costs for the CR and FCG dyad during the study period.
To evaluate follow-up time, we calculated the time during the study for which data were measured as the number of days between hospital discharge and the censor date. We defined censor date as the earliest of the withdrawal date, the last survey date, or the death date. Some FCG submitted a final cost survey after deciding to withdraw from the intervention calls.
Analysis
We estimated unadjusted incidence rate ratios (IRRs) and marginal effects using negative binomial regressions.24 Survey completion rates and follow-up time were similar between intervention and control groups, suggesting the randomization was effective in creating balanced groups for comparison. Thus, the analysis leveraged the randomized design and estimated unadjusted effect estimates.
We mitigated the effect of extreme values for out-of-pocket cost outcomes using the Winsorizing method, which is a common approach to prevent high cost outliers from influencing estimates.25 Based on the distributions, Winsorizing was implemented for healthcare cost outcomes. Specifically, we truncated outliers at the 95th percentile which means cost outcomes >95% were replaced with the value at the 95% of the distribution. We applied this method to the aggregate cost outcomes used in the models (healthcare, lodging, food, transportation) and summed the Winsorized values for the total out-of-pocket spending. We used recycled predictions to generate average marginal effects.26 Non-Winsorized and adjusted results are presented in Supplemental Material Tables S1 and S2. We conducted all analyses in Stata 16.
RESULTS
There were 282 dyads eligible for cost outcomes analysis, with 131 in the attention control group and 151 in the TPC intervention group (Table 1). Most (75.5%) FCGs were from Minnesota, 14.9% were from Iowa, and 9.6% were from Wisconsin. The average age of FCGs was 59 (SD = 12.7) and most (94.4%) participants were White. CR had a mean age of 66 years (range 21–98), 45% identified as female, and 96% identified as non-Hispanic White. There were no significant differences in the characteristics of the control and intervention groups, though missingness was significantly greater in the control group for race, marital status, education, health, income, employment, and employment change. Follow-up time was impacted by the high mortality among this seriously ill CR sample, and mortality rates were similar between groups.2 On average, FCGs participated for 95.5 (SD = 70.7) days and completed 3.6 (SD = 2.1) cost surveys in the 6-month period.
TABLE 1.
Characteristics of family caregivers for transitional palliative care (TPC) and attention control groups.
| Total (N= 282) | TPC (N= 151) | Control (N= 131) | p-Value | |
|---|---|---|---|---|
| Total days, mean ± SD | 95.5 ± 70.7 | 97.1 ± 71.4 | 93.6 ± 70.1 | 0.68 |
| Total surveys, mean ± SD | 3.6 ± 2.1 | 3.6 ± 2.1 | 3.5 ± 2.1 | 0.76 |
| Complete, N (%) | 230 (81.6) | 126 (83.4) | 104 (79.4) | 0.38 |
| Age, mean ± SD | 59.0 ± 12.7 | 58.0 ± 13.1 | 60.1 ± 12.3 | 0.22 |
| Female, N (%) | 199 (70.6) | 108 (71.5) | 91 (69.5) | 0.71 |
| State | 0.19 | |||
| Minnesota, N (%) | 213 (75.5) | 118 (78.1) | 95 (72.5) | |
| Iowa, N (%) | 42 (14.9) | 23 (15.2) | 19 (14.5) | |
| Wisconsin, N (%) | 27 (9.6) | 10 (6.6) | 17 (13.0) | |
| White, N (%) | 266 (94.4) | 145 (95.8) | 121 (92.6) | 0.27 |
| Missing race, N (%) | 31 (11.0) | 8 (5.3) | 23 (17.6) | 0.00 |
| Married, N (%) | 220 (78.0) | 122 (81.0) | 97 (73.8) | 0.18 |
| Missing marital status, N (%) | 37 (13.1) | 9 (6.0) | 28 (21.4) | <0.001 |
| Education | 0.43 | |||
| Less than high school, N (%) | 2 (0.8) | 2 (1.4) | 0 (0.0) | |
| Some high school, N (%) | 1 (0.4) | 0 (0.0) | 1 (1.0) | |
| High school graduate or GED, N (%) | 39 (13.8) | 19 (12.5) | 20 (15.5) | |
| Vocational training, N (%) | 39 (13.8) | 23 (15.3) | 15 (11.7) | |
| Any college, N (%) | 201 (71.3) | 107 (70.8) | 94 (71.8) | |
| Missing education, N (%) | 35 (12.4) | 7 (4.6) | 28 (21.4) | <0.001 |
| FCG medical condition, yes (%) | 155 (54.9) | 89 (58.8) | 65 (49.5) | 0.16 |
| Missing medical condition, N (%) | 155 (54.9) | 89 (58.8) | 65 (49.5) | 0.16 |
| Health status | 0.65 | |||
| Poor, N (%) | 1 (0.4) | 1 (0.7) | 0 (0.0) | |
| Fair, N (%) | 14 (4.9) | 10 (6.3) | 4 (2.9) | |
| Good, N (%) | 124 (43.9) | 64 (42.3) | 61 (46.2) | |
| Very good, N (%) | 112 (39.8) | 59 (39.4) | 53 (40.4) | |
| Excellent, N (%) | 31 (11.0) | 17 (11.3) | 14 (10.6) | |
| Missing health status, N (%) | 36 (12.8) | 9 (6.0) | 27 (20.6) | <0.001 |
| Income status | 0.004 | |||
| Enough to make ends meet, N (%) | 247 (87.7) | 140 (92.9) | 106 (80.8) | |
| Not enough to make ends meet, N (%) | 35 (12.3) | 11 (7.1) | 25 (19.2) | |
| Missing income status, N (%) | 38 (13.5) | 11 (7.3) | 27 (20.6) | 0.001 |
| Employment | 0.43 | |||
| Full-time, N (%) | 124 (44.0) | 67 (44.3) | 57 (43.7) | |
| Part-time, N (%) | 29 (10.3) | 11 (7.1) | 19 (14.6) | |
| Leave of absence, N (%) | 13 (4.5) | 8 (5.0) | 5 (3.9) | |
| Unemployed, N (%) | 27 (9.5) | 15 (10.0) | 11 (8.7) | |
| Retired, N (%) | 89 (31.7) | 51 (33.6) | 38 (29.1) | |
| Missing employment, N (%) | 39 (13.8) | 11 (7.3) | 28 (21.4) | <0.001 |
| Employment status change | 0.39 | |||
| No change, N (%) | 164 (58.3) | 94 (62.1) | 69 (52.9) | |
| Left job or on leave, N (%) | 55 (19.4) | 29 (19.3) | 26 (19.6) | |
| Decreased hours, N (%) | 35 (12.4) | 16 (10.7) | 19 (14.7) | |
| Other change, N (%) | 28 (9.9) | 12 (7.9) | 17 (12.7) | |
| Missing employment status change, N (%) | 40 (14.2) | 11 (7.3) | 29 (22.1) | <0.001 |
| CR discharge disposition | 0.13 | |||
| Home, N (%) | 172 (61.0) | 86 (57.0) | 86 (65.6) | |
| Hospice, N (%) | 49 (17.4) | 31 (20.5) | 18 (13.7) | |
| SNF or rehab, N (%) | 54 (19.1) | 28 (18.5) | 26 (19.8) | |
| Other, N (%) | 7 (2.5) | 6 (4.0) | 1 (0.8) | |
| CR insurance | 0.47 | |||
| Medicare only, N (%) | 152 (53.9) | 79 (52.3) | 73 (55.7) | |
| Any Medicaid, N (%) | 27 (9.6) | 16 (10.6) | 11 (8.4) | |
| Private insurance, N (%) | 96 (34.0) | 54 (35.8) | 42 (32.1) | |
| Other or missing, N (%) | 7 (2.5) | 2 (1.3) | 5 (3.8) |
Note: We collected data on FCGs’ health status, including whether or not they had been diagnosed with a medical condition themselves. Medical conditions were self-reported and included common chronic conditions such as diabetes, asthma, hypertension, and arthritis.
Abbreviations: CR, care recipient; FCG, family caregiver; GED, general education diploma; SNF, skilled nursing facility.
Utilization measures
CR healthcare visits outside of the home and at-home were the most common form of healthcare utilization across the study period. Following discharge from the initial hospitalization, mean reported hospital nights during the study period were 4.0 (SD = 9.1) and 5.3 (SD = 9.5) in TPC versus control CR (unadjusted; Table 2). Rates of hospital use were significantly lower among TPC versus control CR (unadjusted IRR = 0.75; 95% confidence interval [CI] = 0.56–0.99). Using the average marginal effects estimation, we found TPC prevented 1.91 expected hospital nights compared with control (95% CI = 0.14, 3.69). We observed increased rates of emergency department use among FCG in TPC versus control (IRR = 3.58; 95% CI =1.16, 11.06). However, these estimates are unreliable because mean counts among the control group were nearly 0 (<0.1) and relative estimates become unreliable as denominators approach 0.
TABLE 2.
Healthcare utilization for care recipients and family caregivers for transitional palliative care (TPC) and attention control groups.
| Control, mean (SD) | TPC, mean (SD) | Unadjusted IRR, IRR (95% CI) | AME (95% CI) | |
|---|---|---|---|---|
| Healthcare at home visits | 1.8 (2.5) | 2.0 (2.7) | 1.09 (0.78, 1.52) | 0.16 (–0.78, 1.10) |
| Care recipient utilization Visits outside the home | 4.8 (5.9) | 5.2 (7.1) | 1.07 (0.81, 1.42) | 0.23 (–1.01, 1.49) |
| Hospital admissions | 0.8 (1.3) | 0.7 (1.3) | 0.77 (0.52, 1.14) | –0.24 (–0.58, 0.10) |
| Hospital nights | 5.3 (9.5) | 4.0 (9.1) | 0.75 (0.56, 0.99) | –1.92 (–3.70, –0.14) |
| Emergency department visits | 0.3 (0.7) | 0.3 (0.7) | 1.02 (0.62, 1.67) | 0.00 (–0.17, 0.16) |
| Nursing facility admissions | 0.5 (1.2) | 0.6 (1.4) | 1.08 (0.70, 1.65) | 0.02 (–0.24, 0.29) |
| Nursing facility nights | 9.9 (26.8) | 11.3 (31.8) | 0.88 (0.68, 1.15) | –1.73 (–4.94, 1.47) |
| Family caregiver utilization | ||||
| Visits outside the home visits | 1.4 (1.9) | 1.8 (2.5) | 1.13 (0.81, 1.58) | 0.19 (–0.41, 0.79) |
| Hospital admissions | 0.0 (0.1) | 0.0 (0.1) | 2.56 (0.26, 25.12) | 0.01 (0.02, 0.05) |
| Hospital nights | 0.0 (0.0) | 0.1 (0.8) | 0.00 (0.00, 0.00) | 0.76 (–77.47, 79.00) |
| Emergency department visits | 0.0 (0.2) | 0.1 (0.4) | 3.58 (1.16, 11.06) | 0.09 (–0.00, 0.19) |
Note: Rates of health services use are calculated among all included participants and are not conditional on any use of a service. The estimate can be interpreted as the expected number of events during the mean study follow-up time.
Abbreviations: AME, average marginal effect; CI, confidence interval; IRR, incidence rate ratio.
Spending measures
In unadjusted analyses, total out-of-pocket, transportation, food, healthcare coinsurance, and other expenses were not significantly different between TPC and control groups (Table 3). However, lodging costs were significantly lower for TPC versus control (unadj IRR = 0.71; 95% CI = 0.56, 0.89). Mean total out-of-pocket spending for dyads was similar for TPC (mean = $1474.25, SD = $1870.52) and control groups (mean = $1318.40, SD = $1650.29). Healthcare out-of-pocket payments were not significantly different for FCGs in the intervention group (mean = $1135.45; SD = $1726.31) compared with the control group (mean = $948.44; SD = $1450.20). The difference in mean lodging costs for TPC ($91.60; SD = $247.55) versus control group (mean = $129.76, SD = $303.78) was less than $50, though this difference was statistically significant.
TABLE 3.
Out-of-pocket costs accrued over 6-month study period for transitional palliative care (TPC) and attention control (primary analysis, winsorized).
| United States Dollars ($, 2021–2022 USD) | Control, mean (SD) | TPC, mean (SD) | Unadjusted IRR, IRR (95% CI) | AME (95% CI) |
|---|---|---|---|---|
| Total costs | 1318.40 (1650.29) | 1474.25 (1870.52) | 1.12 (0.88, 1.41) | 155.85 (–170.25, 481.94) |
| Healthcare costs | 948.44 (1450.20) | 1135.46 (1726.31) | 1.20 (0.95, 1.51) | 187.03 (–56.35, 430.41) |
| Food costs | 108.21 (182.89) | 106.24 (178.46) | 0.98 (0.78, 1.24) | –1.97 (–27.20, 23.26) |
| Transportation costs | 132.00 (188.90) | 140.94 (212.01) | 1.07 (0.84, 1.35) | –8.94 (–23.05, 40.94) |
| Lodging costs | 129.76 (303.78) | 91.60 (247.55) | 0.71 (0.56, 0.89) | –38.15 (–64.86, –11.45) |
Note: Out-of-pocket healthcare costs may include medical supplies purchased by the family caregiver as well as cost-sharing for medical bills.
Abbreviations: AME, average marginal effect; CI, confidence interval; IRR, incidence rate ratio.
DISCUSSION
In this multi-site trial, the TPC intervention for FCG reduced CR nights in the hospital in the 6 months following hospitalization, with nearly two fewer inpatient nights observed in the intervention group. For many (29%) of the seriously ill CR in the study, the 6-month study period includes their end-of-life care. High hospital use at the end of life is frequently used as a proxy for low-quality end-of-life care, so our finding of decreased hospitalizations may suggest TPC improved end-of-life care and experiences for seriously ill CR.27,28
The TPC intervention is novel due to the focus on the FCGs needs, whereas most palliative care, including hospice care, prioritizes the CR’s needs. The scarcity of palliative services in rural and medically underserved areas in part motivated this intervention to support the FCG. In the study, the majority of CRs were discharged without hospice (82.6%), and hospice use did not vary by treatment arm. The Medicare Hospice benefit provides palliative support for CR with less than 6 months prognosis who no longer seek curative care for their primary diagnosis. However, hospice is not appropriate for all seriously ill beneficiaries and interventions such as TPC can provide support for FCG during care transitions, particularly in rural areas.
This study also fills a gap in understanding of FCG–CR dyad’s out-of-pocket spending in a transitional, post-acute care period.29 Out-of-pocket costs are now recognized as a key patient-centered outcome by the Patient Centered Outcomes Research Institute, yet data on dyadic healthcare-related spending are rarely documented in either administrative or trial data. Across both groups, we found substantial out-of-pocket spending on health-related and caregiving-related services for rural FCGs, with over $1400 in out-of-pocket costs in less than 6 months (FCGs participated for 95.5 days on average). Out-of-pocket costs are distressing to caregivers and contribute to the overall economic cost of caregiving such as lost wages or changes in employment. This financial burden of caregiving contributes to “perceived financial strain,” health, and quality of life for FCG, particularly in rural areas.4
These results should be interpreted carefully due to the limitations. Despite the reduction in hospital nights associated with TPC, we did not observe reductions in reported healthcare cost-sharing for CR and FCGs. Potential explanations might include robust insurance coverage across both groups, differences in the distance to the hospital, which might impact lodging expenses, or general limitations of self-reported data, such as variability in individuals understanding of healthcare out-of-pocket costs. The study design attempted to mitigate variability and recall bias through trained coordinators conducting surveys and using frequent, monthly data collection calls. The relatively small sample size combined with highly variable distributions reduced our power to detect meaningful differences in healthcare use. Increased emergency visits among rural FCGs were unexpected and should be considered with caution. The low event rates among FCGs make interpretation of these results particularly challenging. However, it is possible that the TPC intervention may have elevated awareness of impending issues, prompting FCG to seek necessary emergency care in a timely manner when they may not have otherwise. Further, there were significant differences in missing data on FCG characteristics between the intervention and control groups, which may have been a result of greater rapport built with the intervention group and the study coordinator. Finally, study participants were majority White (94.4%) and had a college education (71.3%), which may limit the generalizability of our findings. Nevertheless, we report these results to inform future studies given the paucity of data around healthcare use for rural FCG.
This study fills a gap in knowledge about the financial burden of out-of-pocket costs on FCGs and contributes to evidence that palliative care interventions reduce unnecessary hospitalization for seriously ill patients. However, the lack of an effect of the intervention on out-of-pocket spending requires further study. Interventions to support FCGs should consider evaluating impacts on out-of-pocket spending as a critical patient-centered outcome.
Supplementary Material
Figure S1. Study flow for randomization and cost survey completion.
Table S1. Out-of-pocket costs accrued by treatment arm, non-winsorized.
Table S2. Healthcare utilization for family care giver (FCG) and care recipient (CR) by treatment arm.
Key points.
In this multi-site trial, transitional palliative care for rural family caregivers reduced nights in the hospital for care recipients, with nearly two fewer nights over the 6 months following the initial discharge to home.
Overall, rural family caregivers and seriously ill care recipients in both treatment groups experienced substantial out-of-pocket economic costs related to healthcare in the 6 months following hospitalization.
Why does this paper matter?
This study fills a gap in knowledge about the financial burden of out-of-pocket costs on family caregivers (FCGs) and contributes to evidence that palliative care interventions reduce unnecessary hospitalization for seriously ill patients. Overall rural FCGs and seriously ill CRs experience substantial out-of-pocket economic costs in the 6 months following hospitalization. Interventions to support FCGs should consider evaluating impacts on out-of-pocket spending as a critical patient-centered outcome.
ACKNOWLEDGMENTS
This study was funded by the National Institutes of Health, National Institute of Nursing Research—NIH-NINR R01NR016433. Dr. Allison Gustavson is supported by the VA Office of Research and Development, Center for Care Delivery and Outcomes Research (CCDOR), CIN 13–406.
Funding information
National Institute of Nursing Research, Grant/Award Number: R01NR016433; VA Office of Research and Development, Center for Care Delivery and Outcomes Research (CCDOR), Grant/Award Number: CIN 13–406
SPONSOR’S ROLE
The sponsor did not have a role in the design, methods, subject recruitment, data collections, analysis, or preparation of the article.
Footnotes
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1. Study flow for randomization and cost survey completion.
Table S1. Out-of-pocket costs accrued by treatment arm, non-winsorized.
Table S2. Healthcare utilization for family care giver (FCG) and care recipient (CR) by treatment arm.