APPENDIX
Target Population and Sampling Method. Our target population was general internists and family practitioners using the Epic electronic medical record (EMR) system and, therefore able, to receive the most recent imaging tests and procedure prices through the Relative Price Education Initiative (RPEI) at Atrius on January 26, 2014.
Between 06/06/2014 and 07/24/2014, we identified the Atrius sites that provided adult primary care. We included 21 of 40 Atrius’ total sites; we excluded 11 sites that only provided pediatrics, specialty care, or radiology only (e.g., endoscopy, MRI) and 8 sites that did not receive the RPEI or did not use Epic for their EMR. We randomly selected 3 of the 21 eligible sites to conduct pilot interviews; we used 18 of 21 sites for the interviews included in the study.
We identified 304 general internists and 15 family practitioners working at eligible Atrius sites. We targeted internists and family practitioners for interviews because this type of physician comprised over half (55%) of the Atrius physician work force and were considered to be the type of physician that did most (70%) of the ordering at Atrius. We excluded physicians who did not provide adult primary care (e.g., a home health physician, pediatricians, sub-specialists) and those who did not work at Atrius Health between the start of the RPEI through the date of the last interview (December 1, 2014).
Appendix Figure 1. Price Display Screenshots in Epic Systems
Single Price
© 2015 Epic Systems Corporation. Confidential.
Appendix Table 1. Semi-Structured Interview Domains and Structured QuestionsI. Gut Reaction to Having Paid Price Information
1. What do you recall about having price information?
2. What was your “gut reaction” to being provided with price information?
II. Use of Price Information During Clinical Practice
3. Could you describe for me:
a. The conversations that you may be having with patients that involve price information?
b. The situations in which you may be using price information as part of your clinical decision-making?
4. To what degree do you feel professionally obligated to:
a. Respond to patients who ask questions related to price information? Initiate conversations with patients about price information?
b. Deliver care that is aligned with evidence-based practice?
c. Deliver care that is aligned with practice standards? Deliver care that is aligned with organizational goals? Do you stand to gain financially at all if you had the patients in the risk contracts do well?
d. Act as a “steward” of health care resources—that is, to take societal concerns about the need to reduce wasteful or low value health care, or to reign in escalating health care costs?
5. Have you experienced any tension between these professional obligations?
III. Physician Responsibilities for Price-Informed Clinical Practice
6. Who bears chief responsibility for discussing price with patients?
7. Is there any way for physicians to not be involved in conversations about price?
IV. Background and Demographic Information
8. Are there experiences that have been particularly important to your developing the perspective that you currently hold?
9. What year did you graduate from residency?
10. What is your %FTE spent in active patient care?
11. What gender do you consider yourself to be?
Participant Recruitment Process. We worked with Atrius’ Research Department and physician lead for the RPEI intervention to recruit physicians for our qualitative interviews. Atrius personnel arranged for us to give an informational presentation at one of their standing Internal Medicine Chief’s meeting 1 month prior to starting interview recruitment. Atrius personnel then introduced our study team to each site’s Internal Medicine Chief and explained how the research collaboration fit with Atrius’ organizational goals. Atrius personnel then introduced our study team to individual physicians via multiple modes of communication (e.g., email, instant messaging, paper).
After initial introductions, our study team sent three rounds of follow-up recruitment emails and EMR-based messaging system to IM and FP physicians to ask for their voluntary participation and to schedule the interview. We also sent flyers through interoffice mail and distributed study information in-person. We did in-person recruiting at sites with little-to-no physicians who responded to our recruitment emails.
Interview Protocol. Our final semi-structured interview protocol had four main domains and 11 questions (Appendix Table 1). We developed our semi-structured interview protocol by starting with a conceptual model that accounted for the fact that asking PCPs about their experiences with price information could be a sensitive process so we began our protocol with questions about awareness and attitudes.(1) It also recognized that physicians’ clinical decision-making is a complex process involving some heuristics or categorical thinking.(2,3) It also included the idea that having price information may shift physicians sense of their need to balance potentially conflicting roles as patient advocates,(1) representatives of evidence-based medicine,(4,5) key members of practices,(6) or stewards of societal resources.(7–10) We pilot tested our interview protocol with 3 PCPs who did not work at Atrius and with 5 Atrius PCPs for content, clarity, pace, and timing.
Interviews, Recordings, Transcription. Two interviewers conducted all the in-person semi-structured interviews (Blinded) between August 26, 2014 and December 1, 2014. All except 2 interviews were audiorecorded. Interviews were transcribed then cleaned by a research assistant concurrently with the interviews.
Analytical Approach. We analyzed semi-structured interviews using grounded theory and the constant comparative method of qualitative analysis.(11) Two initial readers and two adjudicators open-coded a sample of 15 interviews from across the 3 study arms to create a codebook with a hierarchy of codes and code definitions. Two primary coders then close-coded all interviews using Dedoose software. Coders first identified explicit answers to stated questions from the interview protocol, that is, the face-value of the interviewee’s response to a question. We then coded “implicit” answers from across the entirety of the interview, or what an interviewee’s true answer might have been including text and anecdotes from outside the initial answer. For example, if an interviewee is asked their gut reaction to price information and responds, “it was fine”, they receive an explicit neutral code. However, if later in the interview they say, “seeing price information makes me feel bad,” then receive an implicit negative code. We also coded themes across the interviews and theoretical codes based on our conceptual model of professional obligation and clinical decision-making. Memoing was used to refine the conceptual model and describe domains of professional obligation of each interviewee. Coders checked inter-rater reliability throughout the analytical process using 1 in 2 interviews. Overall inter-rater agreement was к = 0.73. We reconciled differences through discussion.
We examined whether responses varied by demographics of age, residency graduation year, percentage of full-time effort spent in clinical care, and whether PCPs had administrative duties.
REFERENCES
1. Levinsky NG. The Doctor’s Master. N Engl J Med. 1984;
2. Calder L a, Forster AJ, Stiell IG, Carr LK, Brehaut JC, Perry JJ, et al. Experiential and rational decision making: a survey to determine how emergency physicians make clinical decisions. Emerg Med J [Internet]. 2012 Oct [cited 2014 Jun 12];29(10):811–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22065868
3. Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022–8.
4. Tracy CS, Dantas GC, Moineddin R, Upshur REG. The nexus of evidence, context, and patient preferences in primary care: postal survey of Canadian family physicians. BMC Fam Pract [Internet]. 2003 Sep 23;4:13. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=212556&tool=pmcentrez&rendertype=abstract
5. Brett AS. Addressing Requests by Patients for Nonbeneficial Interventions. JAMA J Am Med Assoc. 2012;307(2):149.
6. Kitch BT, Desroches C, Lesser C, Cunningham A, Campbell EG. Systems model of physician professionalism in practice. J Eval Clin Pract. 2013;19(1):1–10.
7. Ginsburg S, Bernabeo E, Holmboe E. Doing What Might Be “Wrong.” Acad Med [Internet]. 2014;89(4):664–70. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00001888-201404000-00036
8. Sabbatini AK, Tilburt JC, Campbell EG, Sheeler RD, Egginton JS, Goold SD. Controlling Health Costs: Physician Responses to Patient Expectations for Medical Care. J Gen Intern Med [Internet]. 2014;29(9):1234–41. Available from: http://link.springer.com/10.1007/s11606-014-2898-6
9. Reuben DB, Cassel CK. Physician stewardship of health care in an era of finite resources. JAMA. 2011;306(4):430–1.
10. Chien AT, Rosenthal MB. Annals of Internal Medicine Editorial Waste Not , Want Not : Promoting Efficient Use of Health Care. Ann Intern Med. 2013;158(1):67–9.
11. Miles M H. A. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. [Internet]. Sage Publications. 1994 [cited 2014 Sep 10]. Available from: http://www.sagepub.com/books/Book239534?course=Course10&productType=Books&sortBy=defaultPubDate desc&fs=1
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