A cross-sectional study of financial distress in persons with multimorbidity

Financial hardship among siblings of long-term survivors of childhood cancer: A Childhood Cancer Survivor Study report

BACKGROUND

Siblings of children with cancer may experience adverse household economic consequences, but their financial outcomes in adulthood are unknown.

METHODS

A total of 880 siblings (aged 18-64 years) of adult-aged childhood cancer survivors were surveyed to estimate the prevalence of financial hardship by three established domains (behavioral, material, and psychological). For individual financial hardship items matching the contemporaneous National Health Interview Survey or Behavioral Risk Factor Surveillance System, siblings were compared with the general population by calculating adjusted prevalence odds ratios (ORs) to sample-weighted responses. Multivariable logistic regression models examined associations between sibling characteristics and each hardship domain and between sibling hardship and survivors' cancer/treatment characteristics.

RESULTS

Behavioral, material, and psychological hardship was reported by 24%, 35%, and 28%, respectively. Compared with national survey respondents, siblings were more likely to report worries about medical bills (OR, 1.14; 95% confidence interval [CI], 1.06-1.22), difficulty affording nutritious foods (OR, 1.79; 95% CI, 1.54-2.07), and forgoing needed medical care (OR, 1.38; 95% CI, 1.10-1.73), prescription medications (OR, 2.52; 95% CI, 1.99-3.20), and dental care (OR, 1.34; 95% CI, 1.15-1.57) because of cost. Sibling characteristics associated with reporting financial hardship in one or more domains included female sex, older age, chronic health conditions, lower income, not having health insurance, high out-of-pocket medical expenditures, and nonmedical/nonhome debt. No survivor cancer/treatment characteristics were associated with sibling financial hardship.

CONCLUSIONS

Adult siblings of childhood cancer survivors were more likely to experience financial hardship compared with the general population. Childhood cancer may adversely affect entire households, with potentially lasting implications.

COVID-19 and health care-related financial toxicity in the United States: Evidence from the 2022 National Health Interview Survey

BACKGROUND

Despite the common perception of the socioeconomic burden of the COVID-19 pandemic, quantification of the relationship between COVID-19 and indicators of health care-related financial toxicity in the general population has been limited. This study aimed to provide estimates of these relationships in a nationally representative sample of the US adult population.

METHODS

Using the data on 27,480 adults from the 2022 National Health Interview Survey, we fitted multivariable logistic regression models to assess the differential risks of financial toxicity as manifested by the financial hardship in paying medical bills, delayed and forgone medical care, and medication nonadherence, by COVID-19 diagnosis, severity, and duration of symptoms.

RESULTS

We found that compared to individuals not having COVID-19, individuals with severe symptoms of COVID-19 were 1.86, 1.50, 1.76, and 1.77 times more likely to experience financial hardship, delay medical care, forgo medical care, and skip/delay/take less medication, respectively. Similarly, individuals with symptoms lasting for 3 or more months were 1.94, 1.65, 1.87, and 2.20 times more likely to experience these measures of financial toxicity, respectively.

CONCLUSIONS

The estimates of the relationship between COVID-19 and financial toxicity will facilitate effective communications for policy actions aimed at alleviating the burden of the COVID-19 pandemic.

Financial Well-Being Among US Adults with Vascular Conditions: Differential Impacts Among Blacks and Hispanics

Background

The ability to meet current and ongoing financial obligations, known as financial well-being (FWB), is not only associated with the likelihood of adverse health events but is also affected by unexpected health care expenditures. However, the relationship between FWB and common health outcomes is not well understood. Using data available in the Financial Well-Being Scale from the Consumer Financial Protection Bureau, we evaluated the impact of four vascular conditions-cardiovascular disease (CVD), stroke, high blood pressure (BP), and high cholesterol-on FWB and how these impacts varied between racial and ethnic groups.

Methods

Using the Understanding America Survey-a nationally representative, longitudinal panel-we identified adults with self-reported diagnoses between 2014 and 2020 of high cholesterol, high BP, stroke, and CVD. We used stratified, longitudinal mixed regression models to assess the association between these diagnoses and FWB. Each condition was modeled separately and included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, and an indicator of the condition. Racial and ethnic differentials were captured using group-condition interactions.

Results

On average, Whites had the highest FWB Scale score (69.0, SD=21.8), followed by other races (66.7, SD=21.0), Hispanics (59.3, SD=21.6), and Blacks (56.2, SD=21.4). In general, FWB of individuals with vascular conditions was lower than that of those without, but the impact varied between racial and ethnic groups. Compared with Whites (the reference group), Blacks with CVD (-7.4, SD=1.0), stroke (-8.1, SD=1.5), high cholesterol (-5.7, SD=0.7), and high BP (6.1, SD=0.7) had lower FWB. Similarly, Hispanics with high BP (-3.0, SD=0.6) and CVD (-6.3, SD=1.3) had lower FWB. Income, education, insurance, and marital status were also correlated with FWB.

Conclusions

These results indicated differences in the financial ramifications of vascular conditions among racial and ethnic groups. Findings suggest the need for interventions targeting FWB of individuals with vascular conditions, particularly those from minority groups.

Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans

BACKGROUND

Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services.

OBJECTIVE

To study associations between social risks and primary care utilization among patients with medical complexity.

DESIGN

Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion.

PARTICIPANTS

Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death.

MAIN MEASURES

Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter.

KEY RESULTS

Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of  ≥ 1 social work encounter.

CONCLUSIONS

We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.

Financial Hardship in Adult Survivors of Childhood Cancer in the Era After Implementation of the Affordable Care Act: A Report From the Childhood Cancer Survivor Study

PURPOSE

To estimate the prevalence of financial hardship among adult survivors of childhood cancer compared with siblings and identify sociodemographic, cancer diagnosis, and treatment correlates of hardship among survivors in the era after implementation of the Affordable Care Act.

METHODS

A total of 3,555 long-term (≥ 5 years) survivors of childhood cancer and 956 siblings who completed a survey administered in 2017-2019 were identified from the Childhood Cancer Survivor Study. Financial hardship was measured by 21 survey items derived from US national surveys that had been previously cognitively tested and fielded. Principal component analysis (PCA) identified domains of hardship. Multiple linear regression examined the association of standardized domain scores (ie, scores divided by standard deviation) with cancer and treatment history and sociodemographic characteristics among survivors.

RESULTS

Survivors were more likely than siblings to report hardship in ≥ 1 item (63.4% v 53.7%, P < .001). They were more likely to report being sent to debt collection (29.9% v 22.3%), problems paying medical bills (20.7% v 12.8%), foregoing needed medical care (14.1% v 7.8%), and worry/stress about paying their rent/mortgage (33.6% v 23.2%) or having enough money to buy nutritious meals (26.8% v 15.5%); all P < .001. Survivors reported greater hardship than siblings in all three domains identified by principal component analysis: behavioral hardship (mean standardized domain score 0.51 v 0.35), material hardship/financial sacrifices (0.64 v 0.46), and psychological hardship (0.69 v 0.44), all P < .001. Sociodemographic (eg,

CONCLUSION

Survivors of childhood cancer were more likely to experience financial hardship than siblings. Correlates of hardship can inform survivorship care guidelines and intervention strategies.

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Key Words Collapse

MESH Headings

• United States
• Adult
• Humans
• Child
• Neoplasms/therapy
• Cancer Survivors
• Patient Protection and Affordable Care Act
• Financial Stress
• Cost of Illness
• Survivors
• Surveys and Questionnaires

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Grants

• U24 CA055727 NCI NIH HHS

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Affiliation(s)

Paul C. Nathan The Hospital for Sick Children, Division of Hematology/Oncology, The University of Toronto, Toronto, Ontario, Canada
I-Chan Huang St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Yan Chen University of Alberta, Edmonton, School of Public Health Alberta, Edmonton, Alberta, Canada
Tara O. Henderson University of Chicago Comer Children's Hospital, Section of Pediatric Hematology, Oncology and Stem Cell Transplantation, Chicago, IL
Elyse R. Park Massachusetts General Hospital Cancer Center, Boston, MA
Anne C. Kirchhoff Huntsman Cancer Institute, Cancer Control and Population Sciences, University of Utah, Salt Lake City, UT
Leslie L. Robison St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Kevin Krull St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Wendy Leisenring Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA
Gregory T. Armstrong St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Rena M. Conti Department of Markets, Public Policy and Law, Questrom School of Business, Boston University, Boston, MA
Yutaka Yasui St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
K. Robin Yabroff Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA

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LGCM and PLS-SEM in Panel Survey Data: A Systematic Review and Bibliometric Analysis

The application of Latent Growth Curve Model (LGCM) and Partial Least Square Structural Equation Modeling (PLS-SEM) has gained much attention in panel survey studies. This study explores the distributions and trends of LGCM, and PLS-SEM used in panel survey data. It highlights the gaps in the current and existing approaches of PLS-SEM practiced by researchers in analyzing panel survey data. The integrated bibliometric analysis and systematic review were employed in this study. Based on the reviewed articles, the LGCM and PLS-SEM showed an increasing trend of publication in the panel survey data. Though the popularity of LGCM was more outstanding than PLS-SEM for the panel survey data, LGCM has several limitations such as statistical assumptions, reliable sample size, number of repeated measures, and missing data. This systematic review identified five different approaches of PLS-SEM in analyzing the panel survey data namely pre- and post-approach with different constructs, a path comparison approach, a cross-lagged approach, pre- and post-approach with the same constructs, and an evaluation approach practiced by researchers. None of the previous approaches used can establish one structural model to represent the whole changes in the repeated measure. Thus, the findings of this paper could help researchers choose a more appropriate approach to analyzing panel survey data.

Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

Importance

The bidirectional association between health and financial stability is increasingly recognized.

Objective

To describe the association between chronic disease burden and patients' adverse financial outcomes.

Design, Setting, and Participants

This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan.

Exposures

Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders).

Main Outcomes and Measures

Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt.

Results

The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.

Conclusions and Relevance

This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.

Cost Burden Impacts Cancer Patient Service Utilization Behavior in a US Commercial Plan

Objectives: The burden of affording high-cost medical treatment (eg, cancer therapy) may impact whether some patients choose to access other needed health services within US commercial plans. However, deferring needed care for a mental or behavioral health (M/BH) condition could result in preventable hospital utilization. This research investigates how income level and total out-of-pocket costs (OOPC) interact to influence the service utilization behavior of insured adult cancer patients with a comorbid M/BH diagnosis. Methods: A cross-sectional, retrospective analysis was performed using medical service claims (July 2017-June 2018) and administrative data from eligible members of a large US commercial health benefits plan ( N =5,054). Nonparametric tests were used to examine variation in mean utilization by patient income level and OOPC decile. Negative binomial regression modeling was performed to analyze independent variable effects on count outcomes for outpatient behavioral visits and emergency department (ED) visits. Results: There was significant variation in patient service utilization by income level and total OOPC. Overall, as OOPC increased patients used less outpatient behavioral care ( p <.000). Compared to average and higher incomes, those with lower incomes (<$50,000/year) utilized significantly fewer outpatient visits ( p <.000) and significantly more ED visits ( p <.001) relative to increasing OOPC. Conclusions: The interaction of income level and OOPC (ie, cost burden) could inhibit patients' decision to access supportive behavioral care in the commercial plan. The cumulative cost burden from cancer treatment may promote underutilization of outpatient services and greater ED reliance, particularly among lower income plan members.