Table 1.

Summary of Articles that Examined Patients’ Attitudes toward Cost Communications

Author (year), Country	Population and Characteristics	Site	Sample Size	Willingness to Discuss Costs, %	Costs Discussed, %	Notes
Kelly et al (2015)17, USA	- previously treated metastatic breast, lung, or colorectal cancer pts - 51.1% annual household income > $60,000 - 100% insured	single institution	96	Over 80% - quite or extremely important to know what they would be paying	28% - inferred from 72% reporting never had cost discussions	- patients recruited through participating physicians - show cost per cycle using web-based eviti Advisor - data collected using questionnaire
Bestvina et al (2014),13 USA Zafar et al (2015),14 USA	- adults receiving anticancer therapy - 80% income > $60,000 - 100% insured, 56% private	1 academic cancer center+3 affiliated rural oncology clinics	300	52% had some desire to discuss OOP cost 51% wanted physicians to consider costs when making treatment decisions	19% discussed treatment-related OOP cost	- convenience sample from participating sites - focused on OOP costs - data collected via interviews, baseline and 3-month follow-up - 16% high/overwhelming financial distress, measured using IFDFW scale - 76% thought physicians did not know patients’ OOP costs
Irwin et al (2014),10 USA	- breast cancer pts within 5 yrs of initial diagnosis - 59% annual income ≥ $50,000 - 98% insured	single institution, academic medical center	134	94% felt physicians should talk to pts about costs of care 62% felt physicians should wait for pts to initiate discussion	14% discussed costs	- self-administered, anonymous paper survey - 28% stage IV, 46% on cancer treatment at the time of survey - 44% at least moderate level of financial distress, measured using IFDFW scale - 32% financial hardship due to cancer care costs - 85% medical decisions not affected by costs outside OOP - more interested in OOP costs, less in societal costs
Kaser et al (2010),22 Australia	- breast cancer pts - 77% insured	a national organization	47	96% wished to be informed about high-cost drugs, regardless of affordability	28% discussed high cost drugs with oncologists	- email recruit from BCNA - focused on high cost drugs - telephone interview - of those who discussed, none declined treatment due to financial concerns - 89% comfortable to discuss finances w/ physicians
Hunter et al# (2016),16 USA Hunter et al# (2016),15 USA	- breast cancer pts - 100% insured	nationwide community-based practices	677 breast oncology encounters	Not asked	22% visits contained cost conversations; of those 38% discussed cost-saving strategies 16% OOP cost 22% cost/coverage* 24% COI+	- retrospective, mixed-method analysis of transcribed dialogue from 1755 outpatient visits, sampled from a database of audio-recorded clinical encounters - not limited to cancer, also included pts with depression (n=422), and RA (n=656) - majority of cost conversations were initiated by physicians - second paper focused on different definitions of “costs” to quantify the incidence of cost conversation
Meisenberg et al (2015),23 USA	- pts receiving RT or IV chemotherapy - 61% household income ≥ $50,000 - 98% insured - 73% had cancer diagnosed in previous yr	single institution, outpatient cancer center	132	20% - should receive cost information from oncologists	26.9% - inferred from 73.1% who rarely talked to oncologists about costs	- convenience sample survey - 47% high financial distress, measured by Pearson Financial Wellness Scale - 6.1% reduce medication adherence due to cost of care - few wanted personal finance (11%) or societal costs (10%) to affect deciding treatment option - 28% wanted the lower-cost regimen even if equally effective
Bullock at al (2012),18 USA	- pts with solid tumor malignancies - 61% annual income ≥ $50,000 - 97% insured	single institution, outpatient oncology unit at an academic center	256 171 w/medical record review	59% wanted to discuss OOP costs w/physicians 76% comfortable discussing costs w/physicians	Not asked	- convenience sample, self-administered questionnaire - 30% preferred discussing costs w/ someone other than their physicians - 25% difficult paying cancer care, 14% financial hardship - when making treatment decision, 57% did not consider OOP costs, 42% did not wish their physicians to
Henrikson et al (2014),21 USA	- cancer pts receiving chemo at oncology clinics - 77% household income > $50,000 - 100% insured	a nonprofit integrated healthcare system	22	Not asked	23% discussed with physicians 36% discussed with other health professionals	- pts identified via administrative data - semi-structured telephone interview - no pts reported provider-initiated cost discussions - 54.5% financial concerns related to treatment - 60% physicians were the preferred starting point for cost discussions, 9% physicians should not be cost-concerned
Zafar et al (2013),20 USA	- pts with solid tumors receiving chemo or hormonal therapy - 22% annual household income ≥ $40,000 - 100% insured	academic medical center + a national copayment assistance foundation	254	Not asked	58% discussed with physicians	- baseline survey plus 4 monthly cost diaries - 63% completed at least one cost diary, among those 55% were underinsured@ - 75% applied drug copayment assistance, >25% of them did not discuss costs w/ physicians - 42% significant or catastrophic subjective financial burden - primary aim was to understand the impact of copayment assistance among insured cancer pts
Jung et al (2012),19 USA	- pts with localized prostate cancer, treated with surgery or RT in previous 6-18 months - 54% annual income ≥ $60,000 - 100% insured	single institution, academic medical center	41	61% would like doctor to discuss OOP costs when making treatment recommendation	Not asked	- primary goal: understand pts’ perceptions of treatment-related OOP costs and their effects - recruited from urology and radiation oncology clinics - semi-structured interview + questionnaire - 73% not burdened by OOP costs, 83% treatment choice not affected by OOP costs - when making medical decision: 32% physicians should consider pts’ OOP costs, 37% should consider country's healthcare costs

^#only numbers related to breast cancer was subtracted

⁺cost/coverage: included discussion of patients’ OOP costs or insurance coverage

^*COI: cost-of-illness, discussion of financial costs or insurance coverage related to health or healthcare

^@underinsurance was defined as insured patients whose spent 10% or more of their annual household income on healthcare; BCNA: Breast Cancer Network Australia; chemo: chemotherapy; IFDFW: InCharge Financial Distress/Financial Well-Being; IV: intravenous; OOP: out-of-pocket ; RA: rheumatoid arthritis; RT: radiation; pts: patients.