Deciding Whether to Take Sacubitril/ Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs

Abstract

BACKGROUND: Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorpo-rated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient– cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postap-proval period. METHODS AND RESULTS: We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, con-tinue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. CONCLUSIONS: Although cost conversations were somewhat common in patient– cardiologist encounters in which sacubitril/ valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judg-ments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.