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Evans E, Jacobs M. Diabetes and Financial Well-Being: Differential Hardship Among Vulnerable Populations. Sci Diabetes Self Manag Care 2024:26350106241256324. [PMID: 38853573 DOI: 10.1177/26350106241256324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
PURPOSE The purpose of the study was to examine financial well-being among a diverse population of individuals with and without diabetes. METHODS Data from the Understanding America Survey, a nationally representative, longitudinal panel, were utilized to identify adults with self-reported diabetes diagnoses between 2014 and 2020. We used longitudinal mixed effects regression models to assess the association between diabetes and financial well-being score (FWBS) among racial and ethnic population subgroups. Models included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, employment, and health insurance, incorporating individual- and household-level fixed effects. Racial and ethnic differentials were captured using group-condition interactions. RESULTS Black participants (17.06%) had the highest prevalence of diabetes, followed by White participants (12.2%), "other" racial groups (10.7%), and Hispanic participants (10.0%). In contrast, White participants (M = 67.66, SD = 22.63) and other racial groups (M = 67.99, SD = 18.45) had the highest FWBSs, followed by Hispanic participants (M = 59.31, SD = 22.78) and Black participants (M = 55.86, SD = 25.67). Compared to White participants, Black participants (β = -5.49, SE = 0.71) and Hispanic participants (β = -2.06, SE = 0.63) have significantly lower FWBSs. Compared to males, females (β = -3.25, SE = 0.41) had lower FWBSs among individuals with diabetes. FWBSs of individuals with diabetes was 2.71 points lower (SE = 0.52), on average, than those without diabetes. Education, household size, age, marital status, and income were also significantly associated with FWBSs. CONCLUSIONS Findings suggest potential disparities in the financial ramifications of diabetes among socially marginalized populations.
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Affiliation(s)
- Elizabeth Evans
- Communication Equity and Outcomes Laboratory, Department of Speech, Language and Hearing Sciences, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Molly Jacobs
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
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Park YMM, Baek JH, Lee HS, Elfassy T, Brown CC, Schootman M, Narcisse MR, Ko SH, McElfish PA, Thomsen MR, Amick BC, Lee SS, Han K. Income variability and incident cardiovascular disease in diabetes: a population-based cohort study. Eur Heart J 2024; 45:1920-1933. [PMID: 38666368 DOI: 10.1093/eurheartj/ehae132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 01/07/2024] [Accepted: 02/19/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND AIMS Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D). METHODS Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders. RESULTS High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results. CONCLUSIONS Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.
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Affiliation(s)
- Yong-Moon Mark Park
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jong-Ha Baek
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, South Korea
| | - Hong Seok Lee
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Tali Elfassy
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Clare C Brown
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mario Schootman
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| | - Marie-Rachelle Narcisse
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Pearl A McElfish
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| | - Michael R Thomsen
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Benjamin C Amick
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Seong-Su Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, South Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, 369 Sangdo-ro, Dongjak-gu, Seoul 06978, South Korea
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Gomez SE, Dudum R, Rodriguez F. Inequities in atherosclerotic cardiovascular disease prevention. Prog Cardiovasc Dis 2024; 84:43-50. [PMID: 38734044 PMCID: PMC11176018 DOI: 10.1016/j.pcad.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024]
Abstract
Atherosclerotic cardiovascular (CV) disease (ASCVD) prevention encompasses interventions across the lifecourse: from primordial to primary and secondary prevention. Primordial prevention begins in childhood and involves the promotion of ideal CV health (CVH) via optimizing physical activity, body mass index, blood glucose levels, total cholesterol levels, blood pressure, and sleep while minimizing tobacco use. Primary and secondary prevention of ASCVD thereafter centers around mitigating ASCVD risk factors via medical therapy and lifestyle interventions. Disparities in optimal preventive efforts exist among historically marginalized groups in each of these three prongs of ASCVD prevention. Children and adults with a high burden of social determinants of health also face inequity in preventive measures. Inadequate screening, risk factor management and prescription of preventive therapeutics permeate the care of certain groups, especially women, Black, and Hispanic individuals in the United States. Beyond this, individuals belonging to historically marginalized groups also are much more likely to experience other ASCVD risk-enhancing factors, placing them at higher risk for ASCVD over their lifetime. These disparities translate to worse outcomes, with higher rates of ASCVD and CV mortality among these groups. Possible solutions to promoting equity involve community-based youth lifestyle interventions, improved risk-factor screening, and increasing accessibility to healthcare resources and novel preventive diagnostics and therapeutics.
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Affiliation(s)
- Sofia E Gomez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Ramzi Dudum
- Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, United States.
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Argetsinger S, LeCates RF, Zhang F, Ross-Degnan D, Wharam JF, Arterburn DE, Fernandez A, Lewis KH. Comparison of health care costs following sleeve gastrectomy versus Roux-en-Y gastric bypass among patients with type 2 diabetes. Obesity (Silver Spring) 2024; 32:691-701. [PMID: 38351395 PMCID: PMC11070223 DOI: 10.1002/oby.23997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/22/2023] [Accepted: 12/14/2023] [Indexed: 03/06/2024]
Abstract
OBJECTIVE The objective of this study was to compare the impact of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on overall and diabetes-specific health care costs among patients with type 2 diabetes. METHODS This retrospective cohort study examined patients with type 2 diabetes after SG and RYGB using data from Optum's deidentified Clinformatics® Data Mart database. The matched study group included 9608 patients who underwent SG or RYGB and were enrolled between 2007 and 2019. The primary outcomes assessed were overall and diabetes-specific health care costs. RESULTS Health care costs associated with type 2 diabetes declined substantially in the first few years following both SG and RYGB. RYGB was associated with a larger decrease in pharmacy costs, as well as type 2 diabetes-specific office and laboratory costs. SG was associated with lower total health care costs in the first three follow-up periods and lower acute care costs in the first 2 years after surgery. CONCLUSIONS In this nationwide study, patients with type 2 diabetes at baseline undergoing RYGB appear to experience a reduced need for ambulatory type 2 diabetes monitoring and reduced requirements for antidiabetes medication but, despite this, did not experience an overall medical cost-benefit in the first few years after RYGB versus SG.
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Affiliation(s)
- Stephanie Argetsinger
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston MA
| | - Robert F LeCates
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston MA
| | - Fang Zhang
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston MA
| | - Dennis Ross-Degnan
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston MA
| | - James F. Wharam
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston MA
- Department of Medicine, Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Durham, NC
| | | | - Adolfo Fernandez
- Department of Surgery, Wake Forest University Health Sciences, Winston-Salem NC
| | - Kristina H. Lewis
- Department of Surgery, Wake Forest University Health Sciences, Winston-Salem NC
- Department of Epidemiology & Prevention, Department of Implementation Science, Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem NC
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Kaufman M, McConnell KJ, Rodriguez MI, Stratton K, Richardson D, Snowden JM. Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017. Med Care 2024; 62:109-116. [PMID: 38109156 DOI: 10.1097/mlr.0000000000001958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
BACKGROUND Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. OBJECTIVE To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. METHODS Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. RESULTS Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). CONCLUSIONS Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.
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Affiliation(s)
- Menolly Kaufman
- School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - Maria I Rodriguez
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Kalera Stratton
- School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR
| | - Dawn Richardson
- School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR
| | - Jonathan M Snowden
- School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
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Warraich HJ, Siddiqi HK, Li DG, van Meijgaard J, Vaduganathan M. Pharmacy and neighborhood-level variation in cash price of diabetes medications in the United States. PLoS One 2023; 18:e0294164. [PMID: 38060500 PMCID: PMC10703254 DOI: 10.1371/journal.pone.0294164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 10/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Diabetes medications place significant financial burden on patients but less is known about factors affecting cost variation. OBJECTIVE To examine pharmacy and neighborhood factors associated with cost variation for diabetes drugs in the US. RESEARCH DESIGN, SUBJECTS AND MEASURES We used all-payer US pharmacy data from 45,874 chain and independent pharmacies reflecting 7,073,909 deidentified claims. We divided diabetes drugs into insulins, non-insulin generic medications, and brand name medications. Generalized linear models, stratified by pharmacy type, identified pharmacy and neighborhood factors associated with higher or lower cash price-per-unit (PPU) for each set of drugs. RESULTS Cash PPU was highest for brand name therapies ($149.4±203.2), followed by insulins ($42.4±25.0), and generic therapies ($1.3±4.4). Pharmacy-level price variation was greater for non-insulin generic therapies than insulins or brand name therapies. Chain pharmacies had both lower prices and lesser variation compared with independent pharmacies. CONCLUSIONS Cash prices for diabetes medications in the US can vary considerably and that the greatest degree of price variation occurs in non-insulin generic therapies.
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Affiliation(s)
- Haider J. Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Hasan K. Siddiqi
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Diane G. Li
- GoodRx Inc, Santa Monica, CA, United States of America
| | | | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
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Reynolds EL, Mizokami-Stout K, Putnam NM, Banerjee M, Albright D, Ang L, Lee J, Pop-Busui R, Feldman EL, Callaghan BC. Cost and utilization of healthcare services for persons with diabetes. Diabetes Res Clin Pract 2023; 205:110983. [PMID: 37890702 PMCID: PMC11037241 DOI: 10.1016/j.diabres.2023.110983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 10/29/2023]
Abstract
AIMS Describe and compare healthcare costs and utilization for insured persons with type 1 diabetes (T1D), type 2 diabetes (T2D), and without diabetes in the United States. METHODS Using a nationally representative healthcare claims database, we identified matched persons with T1D, T2D, and without diabetes using a propensity score quasi-randomization technique. In each year between 2009 and 2018, we report costs (total and out-of-pocket) and utilization for all healthcare services and those specific to medications, diabetes-related supplies, visits to providers, hospitalizations, and emergency department visits. RESULTS In 2018, we found out-of-pocket costs and total costs were highest for persons with T1D (out-of-pocket: $2,037.2, total: $25,652.0), followed by T2D (out-of-pocket: $1,543.3, total: $22,408.1), and without diabetes (out-of-pocket: $1,122.7, total: $14,220.6). From 2009 to 2018, out-of-pocket costs were increasing for persons with T1D(+6.5 %) but decreasing for T2D (-7.5 %) and without diabetes (-2.3 %). Medication costs made up the largest proportion of out-of-pocket costs regardless of diabetes status (T1D: 51.4 %, T2D: 55.4 %,without diabetes: 51.1 %). CONCLUSIONS Given the substantial out-of-pocket costs for people with diabetes, especially for those with T1D, providers should screen all persons with diabetes for financial toxicity (i.e., wide-ranging problems stemming from healthcare costs). In addition, policies that aim to lower out-of-pocket costs of cost-effective diabetes related healthcare are needed with a particular focus on medications.
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Affiliation(s)
- Evan L Reynolds
- Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, 1914 Taubman Center SPC 5316, Ann Arbor, MI 48109-5316, USA.
| | - Kara Mizokami-Stout
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Brehm Tower, Suite 5100, SPC 5714, 1000 Wall Street, Ann Arbor, MI 48105, USA.
| | - Nathaniel M Putnam
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA.
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA.
| | - Dana Albright
- Department of Pediatrics, Division of Pediatric Psychology, University of Michigan, C.S. Mott Children's Hospital, Pediatric Psychology Clinic, 1540 East Medical Center Drive Level 5, Ann Arbor, MI 48109-5318, USA.
| | - Lynn Ang
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Brehm Tower, Suite 5100, SPC 5714, 1000 Wall Street, Ann Arbor, MI 48105, USA.
| | - Joyce Lee
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Michigan, Medical Professional Building, Room D3202, Box: 5718, 1522 Simpson Road East, Ann Arbor, MI 48109-5718, USA.
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Brehm Tower, Suite 5100, SPC 5714, 1000 Wall Street, Ann Arbor, MI 48105, USA.
| | - Eva L Feldman
- Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, 1914 Taubman Center SPC 5316, Ann Arbor, MI 48109-5316, USA.
| | - Brian C Callaghan
- Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, 1914 Taubman Center SPC 5316, Ann Arbor, MI 48109-5316, USA.
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Galindo RJ, Trujillo JM, Low Wang CC, McCoy RG. Advances in the management of type 2 diabetes in adults. BMJ MEDICINE 2023; 2:e000372. [PMID: 37680340 PMCID: PMC10481754 DOI: 10.1136/bmjmed-2022-000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/27/2023] [Indexed: 09/09/2023]
Abstract
Type 2 diabetes is a chronic and progressive cardiometabolic disorder that affects more than 10% of adults worldwide and is a major cause of morbidity, mortality, disability, and high costs. Over the past decade, the pattern of management of diabetes has shifted from a predominantly glucose centric approach, focused on lowering levels of haemoglobin A1c (HbA1c), to a directed complications centric approach, aimed at preventing short term and long term complications of diabetes, and a pathogenesis centric approach, which looks at the underlying metabolic dysfunction of excess adiposity that both causes and complicates the management of diabetes. In this review, we discuss the latest advances in patient centred care for type 2 diabetes, focusing on drug and non-drug approaches to reducing the risks of complications of diabetes in adults. We also discuss the effects of social determinants of health on the management of diabetes, particularly as they affect the treatment of hyperglycaemia in type 2 diabetes.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, Miami, Florida, USA
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jennifer M Trujillo
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cecilia C Low Wang
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Rozalina G McCoy
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Institute for Health Computing, Bethesda, Maryland, USA
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Bhandari R, Armenian SH, McCormack S, Natarajan R, Mostoufi-Moab S. Diabetes in childhood cancer survivors: emerging concepts in pathophysiology and future directions. Front Med (Lausanne) 2023; 10:1206071. [PMID: 37675136 PMCID: PMC10478711 DOI: 10.3389/fmed.2023.1206071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023] Open
Abstract
With advancements in cancer treatment and supportive care, there is a growing population of childhood cancer survivors who experience a substantial burden of comorbidities related to having received cancer treatment at a young age. Despite an overall reduction in the incidence of most chronic health conditions in childhood cancer survivors over the past several decades, the cumulative incidence of certain late effects, in particular diabetes mellitus (DM), has increased. The implications are significant, because DM is a key risk factor for cardiovascular disease, a leading cause of premature death in childhood cancer survivors. The underlying pathophysiology of DM in cancer survivors is multifactorial. DM develops at younger ages in survivors compared to controls, which may reflect an "accelerated aging" phenotype in these individuals. The treatment-related exposures (i.e., chemotherapy, radiation) that increase risk for DM in childhood cancer survivors may be more than additive with established DM risk factors (e.g., older age, obesity, race, and ethnicity). Emerging research also points to parallels in cellular processes implicated in aging- and cancer treatment-related DM. Still, there remains marked inter-individual variability regarding risk of DM that is not explained by demographic and therapeutic risk factors alone. Recent studies have highlighted the role of germline genetic risk factors and epigenetic modifications that are associated with risk of DM in both the general and oncology populations. This review summarizes our current understanding of recognized risk factors for DM in childhood cancer survivors to help inform targeted approaches for disease screening, prevention, and treatment. Furthermore, it highlights the existing scientific gaps in understanding the relative contributions of individual therapeutic exposures and the mechanisms by which they exert their effects that uniquely predispose this population to DM following cancer treatment.
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Affiliation(s)
- Rusha Bhandari
- Department of Pediatrics, City of Hope, Duarte, CA, United States
- Department of Population Sciences, City of Hope, Duarte, CA, United States
| | - Saro H. Armenian
- Department of Pediatrics, City of Hope, Duarte, CA, United States
- Department of Population Sciences, City of Hope, Duarte, CA, United States
| | - Shana McCormack
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Rama Natarajan
- Department of Diabetes Complications and Metabolism, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA, United States
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Ayyala-Somayajula D, Dodge JL, Farias A, Terrault N, Lee BP. Healthcare affordability and effects on mortality among adults with liver disease from 2004 to 2018 in the United States. J Hepatol 2023; 79:329-339. [PMID: 36996942 PMCID: PMC10524480 DOI: 10.1016/j.jhep.2023.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/16/2023] [Accepted: 03/19/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND & AIMS Liver disease is associated with substantial morbidity and mortality, likely incurring financial distress (i.e. healthcare affordability and accessibility issues), although long-term national-level data are limited. METHODS Using the National Health Interview Survey from 2004 to 2018, we categorised adults based on report of liver disease and other chronic conditions linked to mortality data from the National Death Index. We estimated age-adjusted proportions of adults reporting healthcare affordability and accessibility issues. Multivariable logistic regression and Cox regression were used to assess the association of liver disease with financial distress and financial distress with all-cause mortality, respectively. RESULTS Among adults with liver disease (n = 19,407) vs. those without liver disease (n = 996,352), those with cancer history (n = 37,225), those with emphysema (n = 7,937), and those with coronary artery disease (n = 21,510), the age-adjusted proportion reporting healthcare affordability issues for medical services was 29.9% (95% CI 29.7-30.1%) vs. 18.1% (95% CI 18.0-18.3%), 26.5% (95% CI 26.3-26.7%), 42.2% (95% CI 42.1-42.4%), and 31.6% (31.5-31.8%), respectively, and for medications: 15.5% (95% CI 15.4-15.6%) vs. 8.2% (95% CI 8.1-8.3%), 14.8% (95% CI 14.7-14.9%), 26.1% (95% CI 26.0-26.2%), and 20.6% (95% CI 20.5-20.7%), respectively. In multivariable analysis, liver disease (vs. without liver disease, vs. cancer history, vs. emphysema, and vs. coronary artery disease) was associated with inability to afford medical services (adjusted odds ratio [aOR] 1.84, 95% CI 1.77-1.92; aOR 1.32, 95% CI 1.25-1.40; aOR 0.91, 95% CI 0.84-0.98; and aOR 1.11, 95% CI 1.04-1.19, respectively) and medications (aOR 1.92, 95% CI 1.82-2.03; aOR 1.24, 95% CI 1.14-1.33; aOR 0.81, 95% CI 0.74-0.90; and aOR 0.94, 95% CI 0.86-1.02, respectively), delays in medical care (aOR 1.77, 95% CI 1.69-1.87; aOR 1.14, 95% CI 1.06-1.22; aOR 0.88, 95% CI 0.79-0.97; and aOR 1.05, 95% CI 0.97-1.14, respectively), and not receiving the needed medical care (aOR 1.86, 95% CI 1.76-1.96; aOR 1.16, 95% CI 1.07-1.26; aOR 0.89, 95% CI 0.80-0.99; aOR 1.06, 95% CI 0.96-1.16, respectively). In multivariable analysis, among adults with liver disease, financial distress (vs. without financial distress) was associated with increased all-cause mortality (aHR 1.24, 95% CI 1.01-1.53). CONCLUSIONS Adults with liver disease face greater financial distress than adults without liver disease and adults with cancer history. Financial distress is associated with increased risk of all-cause mortality among adults with liver disease. Interventions to improve healthcare affordability should be prioritised in this population. IMPACT AND IMPLICATIONS Adults with liver disease use many medical services, but long-term national studies regarding the financial repercussions and the effects on mortality for such patients are lacking. This study shows that adults with liver disease are more likely to face issues affording medical services and prescription medication, experience delays in medical care, and needing but not obtaining medical care owing to cost, compared with adults without liver disease, adults with cancer history, are equally likely as adults with coronary artery disease, and less likely than adults with emphysema-patients with liver disease who face these issues are at increased risk of death. This study provides the impetus for medical providers and policymakers to prioritise interventions to improve healthcare affordability for adults with liver disease.
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Affiliation(s)
- Divya Ayyala-Somayajula
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jennifer L Dodge
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Albert Farias
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Brian P Lee
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Patel MR, Anthony Tolentino D, Smith A, Heisler M. Economic burden, financial stress, and cost-related coping among people with uncontrolled diabetes in the U.S. Prev Med Rep 2023; 34:102246. [PMID: 37252071 PMCID: PMC10209691 DOI: 10.1016/j.pmedr.2023.102246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/02/2023] [Accepted: 05/11/2023] [Indexed: 05/31/2023] Open
Abstract
Granular information on material deprivation including financial and economic well-being among people with diabetes can better inform policy, practice and interventions to support diabetes management. The purpose of this study was to describe in-depth the state of economic burden, financial stress, and coping among people with high A1c. Data came from the 2019-2021 baseline assessment in an ongoing U.S. trial that addresses social determinants of health among people with diabetes and high A1c who report at least one financial burden or cost-related non-adherence (CRN) (n = 600). Mean age of participants was 53 years. Planning behaviors were the most common financial well-being behavior, while savings was least frequently endorsed. Nearly a quarter of participants report spending more than $300 per month out-of-pocket to manage all of their health conditions. Participants reported spending the most out-of-pocket on medications (52%), special foods (40%), doctor's visits (27%), and blood glucose supplies (22%). Along with health insurance, these were also the most cited as sources of financial stress and where assistance. Seventy-two percent reported high levels of financial stress. Maladaptive coping was evident through CRN, and less than half engaged in adaptive coping such as talking to a doctor about cost or using a resource to address their needs. Economic burden, financial stress, and cost-related coping are highly relevant constructs among people with diabetes and high A1cs. More evidence-generation is needed for diabetes self-management programs to address sources of financial stress, facilitate behaviors to enhance financial well-being, and address unmet social needs to alleviate economic burdens.
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Affiliation(s)
- Minal R. Patel
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, United States
| | | | - Alyssa Smith
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, United States
| | - Michele Heisler
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, United States
- Department of Internal Medicine, Michigan Medicine, United States
- U.S. Department of Veterans Affairs VA Ann Arbor Healthcare System, United States
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13
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Sloan CE, Campagna A, Tu K, Doerstling S, Davis JK, Ubel PA. Online Crowdfunding Campaigns for Diabetes-Related Expenses. Ann Intern Med 2023. [PMID: 37307582 DOI: 10.7326/m23-0540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Affiliation(s)
- Caroline E Sloan
- Duke University School of Medicine and Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Ada Campagna
- Center for Advanced Hindsight, Duke University, Durham, North Carolina
| | - Karissa Tu
- University of Washington School of Medicine, Seattle, Washington
| | | | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Peter A Ubel
- Duke University School of Medicine, Duke-Margolis Center for Health Policy, Fuqua School of Business, and Sanford School of Public Policy, Duke University, Durham, North Carolina
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Khera R, Kondamudi N, Liu M, Ayers C, Spatz ES, Rao S, Essien UR, Powell-Wiley TM, Nasir K, Das SR, Capers Q, Pandey A. Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study. Am J Prev Cardiol 2023; 14:100493. [PMID: 37397263 PMCID: PMC10314135 DOI: 10.1016/j.ajpc.2023.100493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Objective To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex. Methods We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models. Results A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending. Conclusion Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Nitin Kondamudi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Mengni Liu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Shreya Rao
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, United States
| | - Utibe R Essien
- Department of Medicine, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, United States
| | - Tiffany M Powell-Wiley
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, National Heart, Lung, and Blood Institute, NIH, 3131 Center Drive, Bethesda, MD, United States
- Intramural Research Program, National Institute on Minority Health and Health Disparities, NIH, 6707 Democracy Boulevard, Suite 800, Bethesda, MD, United States
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist, 6565 Fannin St, Houston, TX, United States
| | - Sandeep R Das
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Quinn Capers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
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Alawode O, Humble S, Herrick CJ. Food insecurity, SNAP participation and glycemic control in low-income adults with predominantly type 2 diabetes: a cross-sectional analysis using NHANES 2007-2018 data. BMJ Open Diabetes Res Care 2023; 11:e003205. [PMID: 37220963 PMCID: PMC10230897 DOI: 10.1136/bmjdrc-2022-003205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/25/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION Diabetes, characterized by elevated blood glucose levels, affects 13% of US adults, 95% of whom have type 2 diabetes (T2D). Social determinants of health (SDoH), such as food insecurity, are integral to glycemic control. The Supplemental Nutrition Assistance Program (SNAP) aims to reduce food insecurity, but it is not clear how this affects glycemic control in T2D. This study investigated the associations between food insecurity and other SDoH and glycemic control and the role of SNAP participation in a national socioeconomically disadvantaged sample. RESEARCH DESIGN AND METHODS Adults with likely T2D and income <185% of the federal poverty level (FPL) were identified using cross-sectional National Health and Nutrition Examination Survey (NHANES) data (2007-2018). Multivariable logistic regression assessed the association between food insecurity, SNAP participation and glycemic control (defined by HbA1c 7.0%-8.5% depending on age and comorbidities). Covariates included demographic factors, clinical comorbidities, diabetes management strategies, and healthcare access and utilization. RESULTS The study population included 2084 individuals (90% >40 years of age, 55% female, 18% non-Hispanic black, 25% Hispanic, 41% SNAP participants, 36% low or very low food security). Food insecurity was not associated with glycemic control in the adjusted model (adjusted OR (aOR) 1.181 (0.877-1.589)), and SNAP participation did not modify the effect of food insecurity on glycemic control. Insulin use, lack of health insurance, and Hispanic or another race and ethnicity were among the strongest associations with poor glycemic control in the adjusted model. CONCLUSIONS For low-income individuals with T2D in the USA, health insurance may be among the most critical predictors of glycemic control. Additionally, SDoH associated with race and ethnicity plays an important role. SNAP participation may not affect glycemic control because of inadequate benefit amounts or lack of incentives for healthy purchases. These findings have implications for community engaged interventions and healthcare and food policy.
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Affiliation(s)
- Oluwatobi Alawode
- Department of Obstetrics and Gynecology, Meharry Medical College, Nashville, Tennessee, USA
| | - Sarah Humble
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Cynthia J Herrick
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipid Research, Washington University in St Louis, St Louis, Missouri, USA
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16
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Seyoum S, Regenstein M, Benoit M, Dieni O, Willis A, Reno K, Clemm C. Cost burden among the CF population in the United States: A focus on debt, food insecurity, housing and health services. J Cyst Fibros 2023; 22:471-477. [PMID: 36710098 DOI: 10.1016/j.jcf.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 12/09/2022] [Accepted: 01/06/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Advancements in the cystic fibrosis (CF) field have resulted in longer lifespans for individuals with CF. This has led to more responsibility for complex care regimens, frequent health care, and prescription medication utilization that are costly and may not be fully covered by health insurance. There are outstanding questions about unmet medical needs among the U.S. population with CF and how the financial burden of CF is associated with debt, housing instability, and food insecurity. METHODS Researchers developed the CF Health Insurance Survey (CF HIS) to survey a convenience sample of people living with CF in the U.S. The sample was weighted to reflect the parameters of the 2019 Cystic Fibrosis Foundation Patient Registry Annual Data Report, and chi-square tests and multiple logistic regression models were conducted. RESULTS A total of 1,856 CF patients in the U.S. were included in the study. Of these, 64% faced a financial burden: 55% of respondents faced debt issues, 26% housing issues, and 33% food insecurity issues. A third reported at least one unmet medical need: 24% faced unmet prescription needs, 12% delayed or shortened a hospitalization, and 10% delayed or skipped a care center visit as a result of the cost of care. CONCLUSIONS People with CF in the U.S. experience high financial burden, which is associated with unmet medical needs. Income is the biggest risk factor for financial burden for people with CF, with people dually covered by Medicare and Medicaid particularly at risk.
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Affiliation(s)
- Semret Seyoum
- Department of Health Policy and Management, the George Washington University, 950 New Hampshire Ave NW #2, Washington, D.C. 20052, USA
| | - Marsha Regenstein
- Department of Health Policy and Management, the George Washington University, 950 New Hampshire Ave NW #2, Washington, D.C. 20052, USA
| | - Marie Benoit
- Department of Health Policy and Management, the George Washington University, 950 New Hampshire Ave NW #2, Washington, D.C. 20052, USA.
| | - Olivia Dieni
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
| | - Anne Willis
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
| | - Kim Reno
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
| | - Cristen Clemm
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
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17
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Narm KE, Wen J, Sung L, Dar S, Kim P, Olson B, Schrager A, Tsay A, Himmelstein DU, Woolhandler S, Shure N, McCormick D, Gaffney A. Chronic Illness in Children and Foregone Care Among Household Adults in the United States: A National Study. Med Care 2023; 61:185-191. [PMID: 36730827 DOI: 10.1097/mlr.0000000000001791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Childhood chronic illness imposes financial burdens that may affect the entire family. OBJECTIVE The aim was to assess whether adults living with children with 2 childhood chronic illnesses-asthma and diabetes-are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses. RESEARCH DESIGN 2009-2018 National Health Interview Survey. SUBJECTS Adult-child dyads, consisting of one randomly sampled child and adult in each family. MEASURES The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child's illness using multivariable logistic regressions adjusted for potential confounders. RESULTS The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16-1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18-2.64). CONCLUSIONS Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.
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Affiliation(s)
- Koh Eun Narm
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Jenny Wen
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Lily Sung
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Sofia Dar
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Paul Kim
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Brady Olson
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Alix Schrager
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Annie Tsay
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - David U Himmelstein
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
- City University of New York at Hunter College, New York, NY
| | - Steffie Woolhandler
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
- City University of New York at Hunter College, New York, NY
| | | | - Danny McCormick
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Adam Gaffney
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
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18
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Peng Ng B, Stewart MP, Kwon S, Hawkins GT, Park C. Dissatisfaction of Out-of-Pocket Costs and Problems Paying Medical Bills Among Medicare Beneficiaries With Type 2 Diabetes. Sci Diabetes Self Manag Care 2023; 49:126-135. [PMID: 36971086 DOI: 10.1177/26350106231163516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Purpose The purpose of the study was to examine the relationship between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills among Medicare beneficiaries with type 2 diabetes. Methods The 2019 Medicare Current Beneficiary Survey Public Use File, a nationally representative sample of Medicare beneficiaries aged ≥65 years with type 2 diabetes, was analyzed (n = 2178). A survey-weighted multivariable logit regression model was conducted to examine the association between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills, adjusted for sociodemographics and comorbidities. Results Among study beneficiaries, 12.6% reported problems paying medical bills. Among those with and without problems paying medical bills, 59.5% and 12.8%, respectively, were dissatisfied with out-of-pocket costs. In the multivariable analysis, beneficiaries who were dissatisfied with out-of-pocket costs were more likely to report problems paying medical bills than those who were satisfied. Younger beneficiaries, beneficiaries with lower incomes, those with functional limitations, and those with multiple comorbidities were more likely to report problems paying medical bills. Conclusions Despite having health care coverage, more than one-tenth of Medicare beneficiaries with type 2 diabetes reported problems paying medical bills, which raises concerns about delaying or forgoing needed medical care due to unaffordability. Screenings and targeted interventions that identify and reduce financial hardships associated with out-of-pocket costs should be prioritized.
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Affiliation(s)
- Boon Peng Ng
- College of Nursing, University of Central Florida, Orlando, Florida
- Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, Florida
| | - Morgan P Stewart
- College of Pharmacy, The University of Texas at Austin, Austin, Texas
| | - Seoyon Kwon
- Department of Statistics and Data Science, University of Central Florida, Orlando, Florida
| | | | - Chanhyun Park
- College of Pharmacy, The University of Texas at Austin, Austin, Texas
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Morris JL, Belcher SM, Jeon B, Godzik CM, Imes CC, Luyster F, Sereika SM, Scott PW, Chasens ER. Financial Hardship and its Associations with Perceived Sleep Quality in Participants with Type 2 Diabetes and Obstructive Sleep Apnea. Chronic Illn 2023; 19:197-207. [PMID: 34866430 PMCID: PMC10043926 DOI: 10.1177/17423953211065002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The purpose of this study was to explore social determinants of health (SDoH), and disease severity as predictors of sleep quality in persons with both Obstructive Sleep Apnea (OSA) and type 2 diabetes (T2D). METHODS Disease severity was measured by Apnea-Hypopnea Index [(AHI) ≥ 5] and HbA1c for glycemic control. SDoH included subjective and objective financial hardship, race, sex, marital status, education, and age. Sleep quality was measured by Pittsburgh Sleep Quality Index (PSQI). RESULTS The sample (N = 209) was middle-aged (57.6 ± 10.0); 66% White and 34% African American; and 54% men and 46% women. Participants carried a high burden of disease (mean AHI = 20.7 ± 18.1, mean HbA1c = 7.9% ± 1.7%). Disease severity was not significantly associated with sleep quality (all p >.05). Worse sleep quality was associated with both worse subjective (b = -1.54, p = .015) and objective (b = 2.58, p <.001) financial hardship. Characteristics significantly associated with both subjective and objective financial hardship included being African American, female, ≤ 2 years post high school, and of younger ages (all p < .01).Discussion: Financial hardship is a more important predictor of sleep quality than disease severity, age, sex, race, marital status, and educational attainment, in patients with OSA and T2D.
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Affiliation(s)
- Jonna L Morris
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
| | - Sarah M Belcher
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
| | - Bomin Jeon
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
| | - Cassandra M Godzik
- 583584Dartmouth-Hitchcock Medical Center
- Geisel School of Medicine at Dartmouth, Department of Psychiatry,46 Centerra Parkway, Lebanon, NH 03766
| | - Christopher C Imes
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
| | - Faith Luyster
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
| | - Susan M Sereika
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
| | - Paul W Scott
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
| | - Eileen R Chasens
- 6614University of Pittsburgh, School of Nursing, 3500 Victoria Street, Pittsburgh PA, 1526
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1048] [Impact Index Per Article: 1048.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Chao GF, Yang J, Thumma JR, Chhabra KR, Arterburn DE, Ryan AM, Telem DA, Dimick JB. Out-of-pocket Costs for Commercially-insured Patients in the Years Following Bariatric Surgery: Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass. Ann Surg 2023; 277:e332-e338. [PMID: 35129487 PMCID: PMC9091055 DOI: 10.1097/sla.0000000000005291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare out-of-pocket (OOP) costs for patients up to 3 years after bariatric surgery in a large, commercially-insured population. SUMMARY OF BACKGROUND DATA More information on OOP costs following bariatric surgery may affect patients' procedure choice. METHODS Retrospective study using the IBM MarketScan commercial claims database, representing patients nationally who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) January 1, 2011 to December 31, 2017. We compared total OOP costs after the surgical episode between the 2 procedures using difference-in-differences analysis adjusting for demographics, comorbidities, operative year, and insurance type. RESULTS Of 63,674 patients, 64% underwent SG and 36% underwent RYGB. Adjusted OOP costs after SG were $1083, $1236, and $1266 postoperative years 1, 2, and 3. For RYGB, adjusted OOP costs were $1228, $1377, and $1369. In our primary analysis, SG OOP costs were $122 (95% confidence interval [CI]: -$155 to -$90) less than RYGB year 1. This difference remained consistent at -$119 (95%CI: -$158 to -$79) year 2 and -$80 (95%CI: -$127 to -$35) year 3. These amounts were equivalent to relative differences of -7%, -7%, and -5% years 1, 2, and 3. Plan features contributing the most to differences were co-insurance years 1, 2, and 3.The largest clinical contributors to differences were endoscopy and outpatient care year 1, outpatient care year 2, and emergency department use year 3. CONCLUSIONS Our study is the first to examine the association between bariatric surgery procedure and OOP costs. Differences between procedures were approximately $100 per year which may be an important factor for some patients deciding whether to pursue SG or gastric bypass.
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Affiliation(s)
- Grace F. Chao
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Veterans Affairs Ann Arbor, Ann Arbor, MI
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Karan R. Chhabra
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - David E. Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Andrew M. Ryan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor, MI
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Dana A. Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
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Valero-Elizondo J, Javed Z, Khera R, Tano ME, Dudum R, Acquah I, Hyder AA, Andrieni J, Sharma G, Blaha MJ, Virani SS, Blankstein R, Cainzos-Achirica M, Nasir K. Unfavorable social determinants of health are associated with higher burden of financial toxicity among patients with atherosclerotic cardiovascular disease in the US: findings from the National Health Interview Survey. Arch Public Health 2022; 80:248. [PMID: 36474300 PMCID: PMC9727868 DOI: 10.1186/s13690-022-00987-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 10/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood. METHODS Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence. RESULTS Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features. CONCLUSIONS An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.
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Affiliation(s)
- Javier Valero-Elizondo
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
| | - Zulqarnain Javed
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Rohan Khera
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Mauricio E Tano
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Ramzi Dudum
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Isaac Acquah
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Adnan A Hyder
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Julia Andrieni
- Population Health and Primary Care, Houston Methodist Hospital, Houston, TX, USA
| | - Garima Sharma
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J Blaha
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Salim S Virani
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Miguel Cainzos-Achirica
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Khurram Nasir
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
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Patel MR, Zhang G, Heisler M, Song PX, Piette JD, Shi X, Choe HM, Smith A, Resnicow K. Measurement and Validation of the Comprehensive Score for Financial Toxicity (COST) in a Population With Diabetes. Diabetes Care 2022; 45:2535-2543. [PMID: 36048837 PMCID: PMC9679256 DOI: 10.2337/dc22-0494] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) is a validated instrument measuring financial distress among people with cancer. The reliability and construct validity of the 11-item COST-FACIT were examined in adults with diabetes and high A1C. RESEARCH DESIGN AND METHODS We examined the factor structure (exploratory factor analysis), internal consistency reliability (Cronbach α), floor/ceiling effects, known-groups validity, and predictive validity among a sample of 600 adults with diabetes and high A1C. RESULTS COST-FACIT demonstrated a two-factor structure with high internal consistency: general financial situation (7-items, α = 0.86) and impact of illness on financial situation (4-items, α = 0.73). The measure demonstrated a ceiling effect for 2% of participants and floor effects for 7%. Worse financial toxicity scores were observed among adults who were women, were below the poverty line, had government-sponsored health insurance, were middle-aged, were not in the workforce, and had less educational attainment (P < 0.01). Worse financial toxicity was observed for those engaging in cost coping behaviors, such as taking less or skipping medicines, delaying care, borrowing money, "maxing out" the limit on credit cards, and not paying bills (P < 0.01). In regression models for the full measure and its two factors, worse financial toxicity was correlated with higher A1C (P < 0.01), higher levels of diabetes distress (P < 0.01), more chronic conditions (P < 0.01), and more depressive symptoms (P < 0.01). CONCLUSIONS Findings support both the reliability and validity of the COST-FACIT tool among adults with diabetes and high A1C levels. More research is needed to support the use of the COST-FACIT tool as a clinically relevant patient-centered instrument for diabetes care.
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Affiliation(s)
- Minal R. Patel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Guanghao Zhang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Michele Heisler
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
- U.S. Department of Veterans Affairs VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Peter X.K. Song
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - John D. Piette
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
- U.S. Department of Veterans Affairs VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Hae Mi Choe
- College of Pharmacy, University of Michigan, Ann Arbor, MI
- University of Michigan Medical Group, Ann Arbor, MI
| | - Alyssa Smith
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
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Disease and debt: Findings from the 2019 Panel Study of Income Dynamics in the United States. Prev Med 2022; 164:107248. [PMID: 36087623 PMCID: PMC10068838 DOI: 10.1016/j.ypmed.2022.107248] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/18/2022] [Accepted: 09/02/2022] [Indexed: 11/20/2022]
Abstract
Medical debt has grown dramatically over the past few decades. While cancer and diabetes are known to be associated with medical debt, little is known about the impact of other medical conditions and health behaviors on medical debt. We analyzed cross-sectional data on 9174 households - spanning lower-income, middle-income, and higher-income based on the Census poverty threshold - participating in the 2019 wave of the nationally representative United States Panel Study of Income Dynamics (PSID). The outcomes were presence of any medical debt and presence of medical debt≥ $2000. Respondents reported on medical conditions (diabetes, cancer, heart disease, chronic lung disease, asthma, arthritis, anxiety disorders, mood disorders) and on health behaviors (smoking, heavy drinking). Medical debt was observed in lower-income households with heart disease (OR = 2.64, p-value = 0.006) and anxiety disorders (OR = 2.16, p-value = 0.02); middle-income households with chronic lung disease (OR = 1.73, p-value = 0.03) and mood disorders (OR = 1.53, p-value = 0.04); and higher-income households with a current smoker (OR = 2.99, p-value<0.001). Additionally, medical debt ≥$2000 was observed in lower-income households with asthma (OR = 2.16, p-value = 0.009) and a current smoker (OR = 1.62, p-value = 0.04); middle income households with hypertension (OR = 1.65, p-value = 0.05). These novel findings suggest that the harms of medical debt extend beyond cancer, diabetes and beyond lower-income households. There is an urgent need for policy and health services interventions to address medical debt in a wider range of disease contexts than heretofore envisioned. Intervention development would benefit from novel conceptual frameworks on the causal relationships between health behaviors, health conditions, and medical debt that center social-ecological influences on all three of these domains.
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Hung A, Sloan CE, Boyd C, Bayliss EA, Hastings SN, Maciejewski ML. Deprescribing medications: Do out-of-pocket costs have a role? J Am Geriatr Soc 2022; 70:3334-3337. [PMID: 35917409 PMCID: PMC10077838 DOI: 10.1111/jgs.17974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Caroline E. Sloan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Susan N. Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Caraballo C, Ndumele CD, Roy B, Lu Y, Riley C, Herrin J, Krumholz HM. Trends in Racial and Ethnic Disparities in Barriers to Timely Medical Care Among Adults in the US, 1999 to 2018. JAMA HEALTH FORUM 2022; 3:e223856. [PMID: 36306118 PMCID: PMC9617175 DOI: 10.1001/jamahealthforum.2022.3856] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Importance Racial and ethnic disparities in delayed medical care for reasons that are not directly associated with the cost of care remain understudied. Objective To describe trends in racial and ethnic disparities in barriers to timely medical care among adults during a recent 20-year period. Design, Setting, and Participants This was a serial cross-sectional study of 590 603 noninstitutionalized adults in the US using data from the National Health Interview Survey from 1999 to 2018. Data analyses were performed from December 2021 through August 2022. Exposures Self-reported race, ethnicity, household income, and sex. Main Outcomes and Measures Temporal trends in disparities regarding 5 specific barriers to timely medical care: inability to get through by telephone, no appointment available soon enough, long waiting times, inconvenient office or clinic hours, and lack of transportation. Results The study cohort comprised 590 603 adult respondents (mean [SE] age, 46.00 [0.07] years; 329 638 [51.9%] female; 27 447 [4.7%] Asian, 83 929 [11.8%] Black, 98 692 [13.8%] Hispanic/Latino, and 380 535 [69.7%] White). In 1999, the proportion of each race and ethnicity group reporting any of the 5 barriers to timely medical care was 7.3% among the Asian group; 6.9%, Black; 7.9%, Hispanic/Latino; and 7.0%, White (P > .05 for each difference compared with White individuals). From 1999 to 2018, this proportion increased across all 4 race and ethnicity groups (by 5.7, 8.0, 8.1, and 5.9 percentage points [pp] among Asian, Black, Hispanic/Latino, and White individuals, respectively; P < .001 for each), slightly increasing the disparities between groups. In 2018, compared with White individuals, the proportion reporting any barrier was 2.1 and 3.1 pp higher among Black and Hispanic/Latino individuals (P = .03 and P = .001, respectively). There was no significant difference in prevalence between Asian and White individuals. There was a significant increase in the difference in prevalence between Black individuals and White individuals who reported delaying care because of long waiting times at the clinic or medical office and because of a lack of transportation (1.5 pp and 1.8 pp; P = .03 and P = .01, respectively). In addition, the difference in prevalence between Hispanic/Latino and White individuals who reported delaying care because of long waiting times increased significantly (2.6 pp; P < .001). Conclusions and Relevance The findings of this serial cross-sectional study of data from the National Health Interview Survey suggest that barriers to timely medical care in the US increased for all population groups from 1999 to 2018, with associated increases in disparities among race and ethnicity groups. Interventions beyond those currently implemented are needed to improve access to medical care and to eliminate disparities among race and ethnicity groups.
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Affiliation(s)
- César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Chima D. Ndumele
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Brita Roy
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Carley Riley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Benning TJ, Heien HC, McCoy RG. Evolution of Clinical Complexity, Treatment Burden, Health Care Use, and Diabetes-Related Outcomes Among Commercial and Medicare Advantage Plan Beneficiaries With Diabetes in the U.S., 2006-2018. Diabetes Care 2022; 45:2299-2308. [PMID: 35926104 PMCID: PMC9643151 DOI: 10.2337/dc21-2623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/18/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To characterize trends in clinical complexity, treatment burden, health care use, and diabetes-related outcomes among adults with diabetes. RESEARCH DESIGN AND METHODS We used a nationwide claims database to identify enrollees in commercial and Medicare Advantage plans who met claims criteria for diabetes between 1 January 2006 and 31 March 2019 and to quantify annual trends in clinical complexity (e.g., active health conditions), treatment burden (e.g., medications), health care use (e.g., ambulatory, emergency department [ED], and hospital visits), and diabetes-related outcomes (e.g., hemoglobin A1c [HbA1c] levels) between 2006 and 2018. RESULTS Among 1,470,799 commercially insured patients, the proportion with ≥10 active health conditions increased from 33.3% (95% CI 33.1-33.4) in 2006 to 38.9% (38.8-39.1) in 2018 (P = 0.001) and the proportion taking three or more glucose-lowering medications increased from 11.6% (11.5-11.7) to 23.1% (22.9-23.2) (P = 0.007). The proportion with HbA1c ≥8.0% (≥64 mmol/mol) increased from 28.0% (27.7-28.3) in 2006 to 30.5% (30.2-30.7) in 2015, decreasing to 27.8% (27.5-28.0) in 2018 (overall trend P = 0.04). Number of ambulatory visits per patient per year decreased from 6.86 (6.84-6.88) to 6.19 (6.17-6.21), (P = 0.001) while ED visits increased from 0.26 (0.257-0.263) to 0.29 (0.287-0.293) (P = 0.001). Among 1,311,903 Medicare Advantage enrollees, the proportion with ≥10 active conditions increased from 51.6% (51.2-52.0) to 65.1% (65.0-65.2) (P < 0.001); the proportion taking three or more glucose-lowering medications was stable at 16.6% (16.3-16.9) and 18.1% (18.0-18.2) (P = 0.98), and the proportion with HbA1c ≥8.0% increased from 17.4% (16.7-18.1) to 18.6% (18.4-18.7) (P = 0.008). Ambulatory visits per patient per year remained stable at 8.01 (7.96-8.06) and 8.17 (8.16-8.19) (P = 0.23), but ED visits increased from 0.41 (0.40-0.42) to 0.66 (0.66-0.66) (P < 0.001). CONCLUSIONS Among patients with diabetes, clinical complexity and treatment burden have increased over time. ED utilization has also increased, and patients may be using ED services for low-acuity conditions.
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Affiliation(s)
- Tyler J. Benning
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Rochester, MN
| | - Herbert C. Heien
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Rozalina G. McCoy
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- OptumLabs, Eden Prairie, MN
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Oseran AS, Sun T, Aggarwal R, Kyalwazi A, Yeh RW, Wadhera RK. Association Between Medicare Program Type and Health Care Access, Acute Care Utilization, and Affordability Among Adults With Cardiovascular Disease. Circ Cardiovasc Qual Outcomes 2022; 15:e008762. [PMID: 36052688 PMCID: PMC9489621 DOI: 10.1161/circoutcomes.121.008762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medicare Advantage plans now provide health insurance coverage to >24 million older adults in the United States, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown. METHODS We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage versus traditional Medicare) with measures of health care access, acute care utilization, and affordability. RESULTS The weighted population included 11 013 437 Medicare beneficiaries, of whom 3 922 104 (35.6%) were enrolled in Medicare Advantage, and 7 091 334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, sex, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% versus 76.0%; P=0.01) and to be college educated (24.2% versus 19.0%; P=0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% versus 88.9%; OR, 1.99 [95% CI, 1.33-2.98)]; however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% versus 11.6%; OR, 1.68 [1.17-2.40]) and to worry about paying medical bills (40.1% versus 33.8%; OR, 1.37 [1.07-1.76]) compared with those enrolled in traditional Medicare. CONCLUSIONS Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared with those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with CVD.
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Affiliation(s)
- Andrew S. Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiology, Massachusetts General Hospital, Boston
| | | | - Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ashley Kyalwazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
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Wang SY, Valero-Elizondo J, Cainzos-Achirica M, Desai NR, Nasir K, Khera R. Measures of Financial Hardship From Health Care Expenses Among Families With a Member With Atherosclerotic Cardiovascular Disease in the US. JAMA HEALTH FORUM 2022; 3:e221962. [PMID: 35977226 PMCID: PMC9308060 DOI: 10.1001/jamahealthforum.2022.1962] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/15/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Patients with atherosclerotic cardiovascular disease (ASCVD) face substantial financial burden from health care costs as assessed by many disparate measures. However, evaluation of the concordance of existing measures and the prevalence of financial burden based on these measures is lacking. Objective To compare subjectively reported and objectively measured financial burden from health care in families of patients with ASCVD. Design Setting and Participants This cross-sectional study used data from the Medical Expenditure Panel Survey, a nationally representative survey of individuals and families in the US, and included all families with 1 or more members with ASCVD from 2014 to 2018. Analyses were conducted from October 2021 to April 2022. Main Outcomes and Measures Using accepted definitions, objective financial hardship represented annual out-of-pocket medical expenses exceeding 20% of annual postsubsistence income, and subjective financial hardship represented self-reported problems paying medical bills or paying them over time. Prevalence of financial hardship was identified based on individual definitions and their concordance was assessed. Factors associated with each type of financial hardship were examined using risk-adjusted survey logistic regression. Multivariable logistic regression was used to model the odds of subjective financial hardship vs objective financial hardship across subgroups. The association between measures of financial hardship and self-reported deferral of care was also assessed. Results Among 10 975 families of patients with ASCVD, representing 22.5 million families nationally (mean [SD] age of index individual, 66 [24] years; estimated 54% men]), 37% experienced either objective or subjective financial hardship. This group included 11% (95% CI, 10%-11%) with objective financial hardship, 21% (95% CI, 20%-22%) with subjective financial hardship, and 5% (95% CI, 5%-6%) with both objective and subjective financial hardship. Mean age was 70 (95% CI, 68-71) years vs 61 (95% CI, 60-62) years for index patients in families reporting objective financial hardship only vs subjective financial hardship only, with no difference in sex (50% [95% CI, 46%-54%] of men vs 49% [95% CI, 47%-52%] of women). In risk-adjusted analyses, among families of patients with ASCVD, patient age of 65 years or older was associated with lower odds of subjective financial hardship than objective financial hardship (odds ratio [OR], 0.39; 95% CI, 0.20-0.76), whereas higher income (OR, 6.08; 95% CI, 3.93-9.42 for an income of >100%-200% of the federal poverty level [FPL] vs ≤100% of the FPL and OR, 20.46; 95% CI, 11.45-36.56 for >200% of FPL vs ≤100% of FPL), public insurance (OR, 6.60; 95% CI, 4.20-10.37), and being uninsured (OR, 5.36; 95% CI, 2.61-10.98) were associated with higher odds of subjective financial hardship than objective financial hardship. Subjective financial hardship alone was associated with significantly higher adjusted odds of self-reporting deferred or forgone care compared with objective financial hardship alone (OR, 2.69; 95% CI, 1.79-4.06). Conclusions and Relevance In this cross-sectional study of US adults, 2 in 5 families of patients with ASCVD experienced health care-related financial hardship, but a focus on objective or subjective measures alone would have captured only half the burden and not identified those deferring health care. The findings suggest that a comprehensive framework that evaluates both objective and subjective measures is essential to monitor financial consequences of health care.
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Affiliation(s)
- Stephen Y. Wang
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Javier Valero-Elizondo
- Center for Outcomes Research, Houston Methodist, Houston, Texas
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas
| | - Miguel Cainzos-Achirica
- Center for Outcomes Research, Houston Methodist, Houston, Texas
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Khurram Nasir
- Center for Outcomes Research, Houston Methodist, Houston, Texas
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
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Caraballo C, Mahajan S, Valero-Elizondo J, Massey D, Lu Y, Roy B, Riley C, Annapureddy AR, Murugiah K, Elumn J, Nasir K, Nunez-Smith M, Forman HP, Jackson CL, Herrin J, Krumholz HM. Evaluation of Temporal Trends in Racial and Ethnic Disparities in Sleep Duration Among US Adults, 2004-2018. JAMA Netw Open 2022; 5:e226385. [PMID: 35389500 PMCID: PMC8990329 DOI: 10.1001/jamanetworkopen.2022.6385] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Historically marginalized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed during recent years. OBJECTIVE To evaluate 15-year trends in racial and ethnic differences in self-reported sleep duration among adults in the US. DESIGN, SETTING, AND PARTICIPANTS This serial cross-sectional study used US population-based National Health Interview Survey data collected from 2004 to 2018. A total of 429 195 noninstitutionalized adults were included in the analysis, which was performed from July 26, 2021, to February 10, 2022. EXPOSURES Self-reported race, ethnicity, household income, and sex. MAIN OUTCOMES AND MEASURES Temporal trends and racial and ethnic differences in short (<7 hours in 24 hours) and long (>9 hours in 24 hours) sleep duration and racial and ethnic differences in the association between sleep duration and age. RESULTS The study sample consisted of 429 195 individuals (median [IQR] age, 46 [31-60] years; 51.7% women), of whom 5.1% identified as Asian, 11.8% identified as Black, 14.7% identified as Hispanic or Latino, and 68.5% identified as White. In 2004, the adjusted estimated prevalence of short and long sleep duration were 31.4% and 2.5%, respectively, among Asian individuals; 35.3% and 6.4%, respectively, among Black individuals; 27.0% and 4.6%, respectively, among Hispanic or Latino individuals; and 27.8% and 3.5%, respectively, among White individuals. During the study period, there was a significant increase in short sleep prevalence among Black (6.39 [95% CI, 3.32-9.46] percentage points), Hispanic or Latino (6.61 [95% CI, 4.03-9.20] percentage points), and White (3.22 [95% CI, 2.06-4.38] percentage points) individuals (P < .001 for each), whereas prevalence of long sleep changed significantly only among Hispanic or Latino individuals (-1.42 [95% CI, -2.52 to -0.32] percentage points; P = .01). In 2018, compared with White individuals, short sleep prevalence among Black and Hispanic or Latino individuals was higher by 10.68 (95% CI, 8.12-13.24; P < .001) and 2.44 (95% CI, 0.23-4.65; P = .03) percentage points, respectively, and long sleep prevalence was higher only among Black individuals (1.44 [95% CI, 0.39-2.48] percentage points; P = .007). The short sleep disparities were greatest among women and among those with middle or high household income. In addition, across age groups, Black individuals had a higher short and long sleep duration prevalence compared with White individuals of the same age. CONCLUSIONS AND RELEVANCE The findings of this cross-sectional study suggest that from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals in the US. The disparities in short sleep duration appear to be highest among women, individuals who had middle or high income, and young or middle-aged adults, which may be associated with health disparities.
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Affiliation(s)
- César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Shiwani Mahajan
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | - Daisy Massey
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Brita Roy
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Carley Riley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Amarnath R. Annapureddy
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Karthik Murugiah
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Johanna Elumn
- SEICHE Center for Health and Justice, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | - Marcella Nunez-Smith
- Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Howard P. Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Chandra L. Jackson
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina
- Intramural Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Caballero J, Jacobs RJ, Ownby RL. Development of a computerized intervention to improve health literacy in older Hispanics with type 2 diabetes using a pharmacist supervised comprehensive medication management. PLoS One 2022; 17:e0263264. [PMID: 35139107 PMCID: PMC8827421 DOI: 10.1371/journal.pone.0263264] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 01/17/2022] [Indexed: 11/19/2022] Open
Abstract
Objective
The primary objective was to develop a computerized culturally adapted health literacy intervention for older Hispanics with type 2 diabetes (T2D). Secondary objectives were to assess the usability and acceptability of the intervention by older Hispanics with T2D and clinical pharmacists providing comprehensive medication management (CMM).
Materials and methods
The study occurred in three phases. During phase I, an integration approach (i.e., quantitative assessments, qualitative interviews) was used to develop the intervention and ensure cultural suitability. In phase II, the intervention was translated to Spanish and modified based on data obtained in phase I. During phase III, the intervention was tested for usability/acceptability.
Results
Thirty participants (25 older Hispanics with T2D, 5 clinical pharmacists) were included in the study. Five major themes emerged from qualitative interviews and were included in the intervention: 1) financial considerations, 2) polypharmacy, 3) social/family support, 4) access to medication/information, and 5) loneliness/sadness. Participants felt the computerized intervention developed was easy to use, culturally appropriate, and relevant to their needs. Pharmacists agreed the computerized intervention streamlined patient counseling, offered a tailored approach when conducting CMM, and could save them time.
Conclusion
The ability to offer individualized patient counseling based on information gathered from the computerized intervention allows for precision counseling. Future studies are needed to determine the effectiveness of the developed computerized intervention on adherence and health outcomes.
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Affiliation(s)
- Joshua Caballero
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, Georgia, United States of America
- * E-mail:
| | - Robin J. Jacobs
- Departments of Health Informatics, Nutrition, Medical Education & Research, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Raymond L. Ownby
- Department of Psychiatry and Behavioral Medicine, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
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Ryu S, Fan L. The Relationship Between Financial Worries and Psychological Distress Among U.S. Adults. JOURNAL OF FAMILY AND ECONOMIC ISSUES 2022; 44:16-33. [PMID: 35125855 PMCID: PMC8806009 DOI: 10.1007/s10834-022-09820-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 05/29/2023]
Abstract
This study examines the association between financial worries and psychological distress among US adults and tests its moderating effects by gender, marital status, employment status, education, and income levels. Data were derived from the cross-sectional 2018 National Health Interview Survey (NHIS) of the adult population. The hierarchical regression analysis revealed that higher financial worries were significantly associated with higher psychological distress. Additionally, the association between financial worries and psychological distress was more pronounced among the unmarried, the unemployed, lower-income households, and renters than their counterparts. The findings suggest that accessible financial counseling programs and public health intervention programs are needed to mitigate financial worries and its negative influences on overall psychological health, with greater attention devoted to vulnerable populations.
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Affiliation(s)
- Soomin Ryu
- School of Public Policy, University of Maryland, 2101 Van Munching Hall, College Park, MD 20742 USA
| | - Lu Fan
- Department of Financial Planning, Housing and Consumer Economics, University of Georgia, 205 Dawson Hall, 305 Sanford Drive, Athens, GA 30602 USA
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2295] [Impact Index Per Article: 1147.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Patel MR, Jagsi R, Resnicow K, Smith SN, Hamel LM, Su C, Griggs JJ, Buchanan D, Isaacson N, Torby M. A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship. Popul Health Manag 2021; 24:710-721. [PMID: 33989065 PMCID: PMC8713277 DOI: 10.1089/pop.2021.0043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Little information has been compiled across studies about existing interventions to mitigate issues of medical financial hardship, despite growing interest in health care delivery. The purpose of this qualitative systematic scoping review was to examine content and outcomes of interventions to address medical financial hardship. PRISMA guidelines were applied to present results using PubMed, Scopus, and CINAHL, published between January 1980 and August 2020. Additional studies were identified through reference lists of selected papers. Included studies focused on mitigating medical financial hardship from out-of-pocket (OOP) health care expenses as an intervention strategy with at least 1 evaluation component. Screening 2412 articles identified 339 articles for full-text review, 12 of which met inclusion criteria. Variation was found regarding targets and outcome measurement of intervention. Primary outcomes were in the following categories: financial outcomes (eg, OOP expenses), behavioral outcomes, psychosocial, health care utilization, and health status. No included studies reported significant reduction in OOP expenses, perceptions of financial burden/toxicity, or health status. However, changes were observed for behavioral outcomes (adherence to treatment, patient needs addressed), some psychosocial outcomes (mental health symptoms, perceived support, patient satisfaction), and care utilization such as routine health care. No patterns were observed in the achievement of outcomes across studies based on intensity of intervention. Few rigorous studies exist in this emerging field, and studies have not shown consistent positive effects. Future research should focus on conceptual clarity of the intervention, align outcome measurement and achieve consensus around outcomes, and employ rigorous study designs, measurement, and outcome follow-up.
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Affiliation(s)
- Minal R. Patel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Reshma Jagsi
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Shawna N. Smith
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Lauren M. Hamel
- Wayne State University School of Medicine/Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Christopher Su
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Internal Medicine-Hematology and Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jennifer J. Griggs
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Department of Internal Medicine-Hematology and Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
- Michigan Oncology Quality Consortium, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Diamond Buchanan
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Nicole Isaacson
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Michelle Torby
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Livingston KA, Freeman KJ, Friedman SM, Stout RW, Lianov LS, Drozek D, Shallow J, Shurney D, Patel PM, Campbell TM, Pauly KR, Pollard KJ, Karlsen MC. Lifestyle Medicine and Economics: A Proposal for Research Priorities Informed by a Case Series of Disease Reversal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111364. [PMID: 34769879 PMCID: PMC8583680 DOI: 10.3390/ijerph182111364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 12/20/2022]
Abstract
Chronic disease places an enormous economic burden on both individuals and the healthcare system, and existing fee-for-service models of healthcare prioritize symptom management, medications, and procedures over treating the root causes of disease through changing health behaviors. Value-based care is gaining traction, and there is a need for value-based care models that achieve the quadruple aim of (1) improved population health, (2) enhanced patient experience, (3) reduced healthcare costs, and (4) improved work life and decreased burnout of healthcare providers. Lifestyle medicine (LM) has the potential to achieve these four aims, including promoting health and wellness and reducing healthcare costs; however, the economic outcomes of LM approaches need to be better quantified in research. This paper demonstrates proof of concept by detailing four cases that utilized an intensive, therapeutic lifestyle intervention change (ITLC) to dramatically reverse disease and reduce healthcare costs. In addition, priorities for lifestyle medicine economic research related to the components of quadruple aim are proposed, including conducting rigorously designed research studies to adequately measure the effects of ITLC interventions, modeling the potential economic cost savings enabled by health improvements following lifestyle interventions as compared to usual disease progression and management, and examining the effects of lifestyle medicine implementation upon different payment models.
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Affiliation(s)
- Kara A. Livingston
- American College of Lifestyle Medicine, Chesterfield, MO 63006, USA; (K.A.L.); (L.S.L.); (D.D.); (D.S.); (P.M.P.)
| | - Kelly J. Freeman
- Department of Member Engagement & Administration, American College of Lifestyle Medicine, Chesterfield, MO 63006, USA; (K.J.F.); (K.R.P.)
- School of Nursing, Indiana University, Indianapolis, IN 46202, USA
| | - Susan M. Friedman
- School of Medicine and Dentistry, University of Rochester, Rochester, NY 14620, USA;
| | - Ron W. Stout
- Ardmore Institute of Health, Ardmore, OK 73401, USA;
| | - Liana S. Lianov
- American College of Lifestyle Medicine, Chesterfield, MO 63006, USA; (K.A.L.); (L.S.L.); (D.D.); (D.S.); (P.M.P.)
- Global Positive Health Institute, Sacramento, CA 95825, USA
| | - David Drozek
- American College of Lifestyle Medicine, Chesterfield, MO 63006, USA; (K.A.L.); (L.S.L.); (D.D.); (D.S.); (P.M.P.)
- Department of Specialty Medicine, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH 45701, USA
| | | | - Dexter Shurney
- American College of Lifestyle Medicine, Chesterfield, MO 63006, USA; (K.A.L.); (L.S.L.); (D.D.); (D.S.); (P.M.P.)
- BlueZones Well-Being Institute, Adventist Health, Roseville, CA 95661, USA
| | - Padmaja M. Patel
- American College of Lifestyle Medicine, Chesterfield, MO 63006, USA; (K.A.L.); (L.S.L.); (D.D.); (D.S.); (P.M.P.)
- Midland Health, Midland, TX 79703, USA
| | | | - Kaitlyn R. Pauly
- Department of Member Engagement & Administration, American College of Lifestyle Medicine, Chesterfield, MO 63006, USA; (K.J.F.); (K.R.P.)
| | - Kathryn J. Pollard
- Department of Research, American College of Lifestyle Medicine, Chesterfield, MO 63006, USA;
| | - Micaela C. Karlsen
- Department of Research, American College of Lifestyle Medicine, Chesterfield, MO 63006, USA;
- Correspondence:
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Ng MSN, Chan DNS, Cheng Q, Miaskowski C, So WKW. Association between Financial Hardship and Symptom Burden in Patients Receiving Maintenance Dialysis: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189541. [PMID: 34574463 PMCID: PMC8464840 DOI: 10.3390/ijerph18189541] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many patients on maintenance dialysis experience financial hardship. Existing studies are mainly cost analyses that quantify financial hardship in monetary terms, but an evaluation of its impact is also warranted. This review aims to explore the definition of financial hardship and its relationship with symptom burden among patients on dialysis. METHODS A literature search was conducted in November 2020, using six electronic databases. Studies published in English that examined the associations between financial hardship and symptom burden were selected. Two reviewers independently extracted data and appraised the studies by using the JBI Critical Appraisal Checklists. RESULTS Fifty cross-sectional and seven longitudinal studies were identified. Studies used income level, employment status, healthcare funding, and financial status to evaluate financial hardship. While relationships between decreased income, unemployment, and overall symptom burden were identified, evidence suggested that several symptoms, including depression, fatigue, pain, and sexual dysfunction, were more likely to be associated with changes in financial status. CONCLUSION Our findings suggest that poor financial status may have a negative effect on physical and psychological well-being. However, a clear definition of financial hardship is warranted. Improving this assessment among patients on dialysis may prompt early interventions and minimize the negative impact of financial hardship.
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Affiliation(s)
- Marques Shek Nam Ng
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (M.S.N.N.); (Q.C.); (W.K.W.S.)
| | - Dorothy Ngo Sheung Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (M.S.N.N.); (Q.C.); (W.K.W.S.)
- Correspondence: ; Tel.: +852-3943-8165
| | - Qinqin Cheng
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (M.S.N.N.); (Q.C.); (W.K.W.S.)
| | - Christine Miaskowski
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, CA 94143, USA;
| | - Winnie Kwok Wei So
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (M.S.N.N.); (Q.C.); (W.K.W.S.)
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Lago-Hernandez C, Nguyen NH, Khera R, Loomba R, Asrani SK, Singh S. Financial Hardship From Medical Bills Among Adults With Chronic Liver Diseases: National Estimates From the United States. Hepatology 2021; 74:1509-1522. [PMID: 33772833 DOI: 10.1002/hep.31835] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Chronic liver diseases (CLD) affect approximately 2% of the U.S. population and are associated with substantial burden of hospitalization and costs. We estimated the national burden and consequences of financial hardship from medical bills in individuals with CLD. APPROACH AND RESULTS Using the National Health Interview Survey from 2014 to 2018, we identified individuals with self-reported CLD. We used complex weighted survey analysis to obtain national estimates of financial hardship from medical bills and other financial toxicity measures (eg, cost-related medication nonadherence, personal and/or health care-related financial distress, food insecurity). We evaluated the association of financial hardship from medical bills with unplanned health care use and work productivity, accounting for differences in age, sex, race/ethnicity, insurance, income, education, and comorbidities. Of the 3,666 (representing 5.3 million) U.S. adults with CLD, 1,377 (representing 2 million [37%, 95% CI: 35%-39%]) reported financial hardship from medical bills, including 549 (representing 740,000 [14%, 95% CI: 13%-16%]) who were unable to pay medical bills at all. Adults who were unable to pay medical bills had 8.4-times higher odds of cost-related medication nonadherence (adjusted OR [aOR], 8.39 [95% CI, 5.72-12.32]), 6.3-times higher odds of financial distress (aOR, 6.33 [4.44-9.03]), and 5.6-times higher odds of food insecurity (aOR, 5.59 [3.74-8.37]), as compared to patients without financial hardship from medical bills. Patients unable to pay medical bills had 1.9-times higher odds of emergency department visits (aOR, 1.85 [1.33-2.57]) and 1.8-times higher odds of missing work due to disease (aOR, 1.83 [1.26-2.67]). CONCLUSIONS One in 3 adults with CLD experience financial hardship from medical bills, and frequently experience financial toxicity and unplanned healthcare use. These financial determinates of health have important implications in the context of value-based care.
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Affiliation(s)
- Carlos Lago-Hernandez
- Division of Hospital Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA
| | - Nghia H Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego, La Jolla, CA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego, La Jolla, CA
- NAFLD Research Center, Department of Medicine, University of California, San Diego, La Jolla, CA
| | | | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego, La Jolla, CA
- Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla, CA
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Kenworthy N. Like a Grinding Stone: How Crowdfunding Platforms Create, Perpetuate, and Value Health Inequities. Med Anthropol Q 2021; 35:327-345. [PMID: 33711178 PMCID: PMC8519036 DOI: 10.1111/maq.12639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/17/2020] [Accepted: 01/12/2021] [Indexed: 12/01/2022]
Abstract
This article explores how inequities are reproduced by, and valued within, the increasingly ubiquitous world of medical crowdfunding. As patients use platforms like GoFundMe to solicit donations for health care, success stories inundate social media. But most crowdfunders experience steep odds and marginal benefits. Drawing on the problematic figure of the "black box" in health disparities research and technology studies, I offer ethnography as a tool for unpacking often inscrutable and complex pathways through which online platforms amplify inequities. By leveraging both online and traditional research strategies-a platform analysis and paired narratives of crowdfunders' disparate experiences, drawn from open-ended interviews-this article explores how inequities are created and experienced by users. The analysis highlights how inequities are simultaneously central to the functioning of this marketplace and occluded by its platform design. Consequently, crowdfunding is concealing health inequities while shifting public values about who is entitled to health care, and why.
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Affiliation(s)
- Nora Kenworthy
- School of Nursing and Health StudiesUniversity of Washington Bothell
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Mahajan S, Caraballo C, Lu Y, Valero-Elizondo J, Massey D, Annapureddy AR, Roy B, Riley C, Murugiah K, Onuma O, Nunez-Smith M, Forman HP, Nasir K, Herrin J, Krumholz HM. Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018. JAMA 2021; 326:637-648. [PMID: 34402830 PMCID: PMC8371573 DOI: 10.1001/jama.2021.9907] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 06/01/2021] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades. OBJECTIVE To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults. EXPOSURES Self-reported race, ethnicity, and income level. MAIN OUTCOMES AND MEASURES Rates and racial and ethnic differences in self-reported health status and health care access and affordability. RESULTS The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification. CONCLUSIONS AND RELEVANCE In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.
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Affiliation(s)
- Shiwani Mahajan
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | - Daisy Massey
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Amarnath R. Annapureddy
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Brita Roy
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Carley Riley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Karthik Murugiah
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Oyere Onuma
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marcella Nunez-Smith
- Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Howard P. Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Park J, Zhang P, Wang Y, Zhou X, Look KA, Bigman ET. High Out-of-pocket Health Care Cost Burden Among Medicare Beneficiaries With Diabetes, 1999-2017. Diabetes Care 2021; 44:1797-1804. [PMID: 34183427 PMCID: PMC8376067 DOI: 10.2337/dc20-2708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/17/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We examined the magnitude of and trends in the burden of out-of-pocket (OOP) costs among Medicare beneficiaries age 65 years or older with diabetes overall, by income level, by race/ethnicity, and compared with beneficiaries without diabetes. RESEARCH DESIGN AND METHODS Using data from the 1999-2017 Medicare Current Beneficiary Survey, we estimated average annual per capita OOP costs and percentage of beneficiaries experiencing high OOP burden, defined as OOP costs >10% or >20% of household income. We used joinpoint regression to examine the trends and generalized linear model and logistic regression for comparisons between beneficiaries with and without diabetes. Cost and income estimates were adjusted to 2017 USD. RESULTS Total OOP costs were $3,609-$5,283, with significant increases until 2005 followed by a leveling off. The prevalence of high OOP burden was 57%-72% at the 10% income threshold and 29%-41% at the 20% threshold, with significant increasing trends until 2003 followed by decreases. Total OOP costs were the highest in the ≥75% income quartile, whereas prevalence of high OOP burden was highest in the <25% and 25-50% income quartiles. Non-Hispanic Whites had the highest OOP costs and prevalence of high OOP burden. Beneficiaries with diabetes had significantly higher OOP costs ($498, P < 0.01) and were more likely to have high OOP burden than those without diabetes (odds ratios 1.32 and 1.25 at >10% and >20% thresholds, respectively, P < 0.01). CONCLUSIONS Over the past two decades, Medicare beneficiaries age 65 years or older with diabetes have faced substantial OOP burden, with large income-related disparities.
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Affiliation(s)
- Joohyun Park
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Yu Wang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kevin A Look
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Madison, WI
| | - Elizabeth T Bigman
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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Nguyen NH, Khera R, Ohno-Machado L, Sandborn WJ, Singh S. Prevalence and Effects of Food Insecurity and Social Support on Financial Toxicity in and Healthcare Use by Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2021; 19:1377-1386.e5. [PMID: 32526341 PMCID: PMC7987215 DOI: 10.1016/j.cgh.2020.05.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We estimated the prevalence of social determinants of health (SDH, food insecurity and social support) in adults with inflammatory bowel diseases (IBD) in the United States and evaluated associations with financial toxicity and healthcare use. METHODS In the National Health Interview Survey 2015, we identified adults with IBD and estimated the prevalence of food insecurity and/or lack of social support. We evaluated associations with financial toxicity (financial hardship due to medical bills, personal and health-related financial distress, cost-related medication nonadherence, healthcare affordability) and emergency department use. RESULTS Of estimated 3.1 million adults with IBD in the US, 42% or estimated 1,277,215 patients with IBD reported at least one negative SDH, with 12% reporting both food insecurity and lack of social support. On multivariable analysis adjusting for age, sex, race, family income and comorbidities, patients with food insecurity were significantly more likely to experience financial hardship due to medical bills (odds ratio [OR], 3.31; 95% CI, 1.48-7.39), financial distress (OR, 6.92; 95% CI, 2.28-21.0) and cost-related medication non-adherence (OR, 8.07; 95% CI, 3.16-20.6). Similarly, patients with inadequate social support were significantly more likely to experience financial hardship due to medical bills (OR, 2.98; 95% CI, 1.56-5.67), financial distress (OR, 3.05; 95% CI, 1.64-5.67) and cost-related medication non-adherence (OR, 2.71; 95% CI, 1.10-6.66). Food insecurity and/or lack of social support was not associated with increased risk of emergency department use. CONCLUSIONS In an analysis of data from the National Health Interview Survey 2015, we found that 1 in 8 patients with IBD have food insecurity and lack social support, which is associated with higher financial toxicity. Patients with IBD should be assessed for SDH to tailor healthcare delivery and improve population health.
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Affiliation(s)
- Nghia H. Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - William J. Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
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Acquah I, Valero-Elizondo J, Javed Z, Ibrahim HN, Patel KV, Ryoo Ali HJ, Menser T, Khera R, Cainzos-Achirica M, Nasir K. Financial Hardship Among Nonelderly Adults With CKD in the United States. Am J Kidney Dis 2021; 78:658-668. [PMID: 34144103 DOI: 10.1053/j.ajkd.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/10/2021] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE The burden of financial hardship among individuals with chronic kidney disease (CKD) has not been extensively studied. Therefore, we describe the scope and determinants of financial hardship among a nationally representative sample of adults with CKD. STUDY DESIGN Cross-sectional. SETTING & PARTICIPANTS Nonelderly adults with CKD from the 2014-2018 National Health Interview Survey. EXPOSURE Sociodemographic and clinical characteristics. OUTCOME Financial hardship based on medical bills and consequences of financial hardship (high financial distress, food insecurity, cost-related medication nonadherence, delayed/forgone care due to cost). Financial hardship was categorized into 3 levels: no financial hardship, financial hardship but able to pay bills, and unable to pay bills at all. Financial hardship was then modeled in 2 different ways: (1) any financial hardship (regardless of ability to pay) versus no financial hardship and (2) inability to pay bills versus no financial hardship and financial hardship but able to pay bills. ANALYTICAL APPROACH Nationally representative estimates of financial hardship from medical bills were computed. Multivariable logistic regression models were used to examine the associations of sociodemographic and clinical factors with the outcomes of financial hardship based on medical bills. RESULTS A total 1,425 individuals, representing approximately 2.1 million Americans, reported a diagnosis of CKD within the past year, of whom 46.9% (95% CI, 43.7%-50.2%) reported experiencing financial hardship from medical bills; 20.9% (95% CI, 18.5%-23.6%) reported inability to pay medical bills at all. Lack of insurance was the strongest determinant of financial hardship in this population (odds ratio, 4.06 [95% CI, 2.18-7.56]). LIMITATIONS Self-reported nature of CKD diagnosis. CONCLUSIONS Approximately half the nonelderly US population with CKD experiences financial hardship from medical bills that is associated strongly with lack of insurance. Evidence-based clinical and policy interventions are needed to address these hardships.
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Affiliation(s)
- Isaac Acquah
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Zulqarnain Javed
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Hassan N Ibrahim
- Division of Renal Disease and Hypertension, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Kershaw V Patel
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Hyeon-Ju Ryoo Ali
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Terri Menser
- Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Rohan Khera
- Yale University School of Medicine, New Haven, Connecticut
| | - Miguel Cainzos-Achirica
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas.
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Liu P, Zhou L, Tian Y, Nie W. Association between household debt and depressive mood among Chinese residents. Public Health 2021; 194:202-207. [PMID: 33962097 DOI: 10.1016/j.puhe.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/25/2021] [Accepted: 03/07/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The aim of this study was to examine the association of household debt and depressive mood among Chinese adults and to evaluate whether the association varies across types of debt. STUDY DESIGN This is a secondary data analysis of a nationally representative survey. METHODS A prospective cohort study of participants was drawn from the China Family Panel Studies (CFPS). In total, 5135 participants had their depressive mood measured in the CFPS starting from 2014 to 2016 and had participated in the biennial survey. We used logistic regression models to identify predictors of depressive mood with debts, sociodemographic factors, health status factors and health behaviors factors. Adjusted for all measured covariates, we conducted an independent analysis for the experience of housing loans from formal institutions (HLFI), other loans from formal institutions (OLFI), housing loans from relatives and friends (HLRF) and other loans from relatives and friends (OLRF). RESULTS Multiple logistic regression analyses revealed that household debt was a significant risk factor for depressive mood (1.35; 95% confidence interval [CI], 1.19-1.54), after controlling for potential confounders. Independent analysis revealed that HLFI was not a significant predictor, while HLRF (1.26; 95% CI, 1.08-1.48), OLFI (1.45; 95% CI, 1.13-1.87) and OLRF (1.23; 95% CI, 1.02-1.47) remained significant risk factors. CONCLUSION OLFI, HLRF and OLRF were associated with depressive mood, while HLFI was not. To address the problem of individual depressive mood, its apparent association with household debt should be paid more attention.
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Affiliation(s)
- P Liu
- Department of Economics, School of Economics, Qingdao University, 62nd Kedazhi Road, Laoshan District, Qingdao, 266061, PR China.
| | - L Zhou
- Department of Economics, School of Economics, Qingdao University, 62nd Kedazhi Road, Laoshan District, Qingdao, 266061, PR China
| | - Y Tian
- Business School, The University of Sydney, Sydney, Australia
| | - W Nie
- Department of Business Management, School of Management, Ocean University of China, Qingdao, PR China
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Prevalence of cardiovascular risk factors in a nationally representative adult population with inflammatory bowel disease without atherosclerotic cardiovascular disease. Am J Prev Cardiol 2021; 6:100171. [PMID: 34327497 PMCID: PMC8315477 DOI: 10.1016/j.ajpc.2021.100171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/01/2021] [Accepted: 03/07/2021] [Indexed: 01/08/2023] Open
Abstract
Background and aims Chronic inflammation is associated with premature atherosclerotic cardiovascular disease (ASCVD). We studied the prevalence of cardiovascular risk factors (CRFs) amongst individuals with IBD who have not developed ASCVD. Methods Our study population was derived from the 2015 – 2016 National Health Interview Survey. Those with ASCVD (defined as myocardial infarction, angina or stroke) were excluded. The prevalence of CRFs among individuals with IBD was compared with those without IBD. The odds CRFs among adults with IBD was assessed using logistic regression models. Results In our study population of 60,155 individuals, 786 (1.3%) had IBD. IBD was associated with increased odds hypertension (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.39–2.09), diabetes (OR 1.68, 95% CI 1.22–2.32), hypercholesterolemia (OR 1.62, 95% CI 1.32–2.99) and insufficient physical activity (OR 1.38, 95% CI 1.16–1.66). Conclusion IBD is associated with higher prevalence of CRFs. Early screening and risk mitigation strategies are warranted.
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 2963] [Impact Index Per Article: 987.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Caraballo C, Massey D, Mahajan S, Lu Y, Annapureddy AR, Roy B, Riley C, Murugiah K, Valero-Elizondo J, Onuma O, Nunez-Smith M, Forman HP, Nasir K, Herrin J, Krumholz HM. Racial and Ethnic Disparities in Access to Health Care Among Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.10.30.20223420. [PMID: 33173905 PMCID: PMC7654899 DOI: 10.1101/2020.10.30.20223420] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Racial and ethnic disparities plague the US health care system despite efforts to eliminate them. To understand what has been achieved amid these efforts, a comprehensive study from the population perspective is needed. OBJECTIVES To determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades. DESIGN Cross-sectional. SETTING Data from the National Health Interview Survey, 1999-2018. PARTICIPANTS Individuals >18 years old. EXPOSURE Race and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic. MAIN OUTCOME AND MEASURES Rates of lack of insurance coverage, lack of a usual source of care, and foregone/delayed medical care due to cost. We also estimated the gap between non-Hispanic White and the other subgroups for these outcomes. RESULTS We included 596,355 adults, of which 69.7% identified as White, 11.8% as Black, 4.7% as Asian, and 13.8% as Hispanic. The proportion uninsured and the rates of lacking a usual source of care remained stable across all 4 race/ethnicity subgroups up to 2009, while rates of foregone/delayed medical care due to cost increased. Between 2010 and 2015, the percentage of uninsured diminished for all, with the steepest reduction among Hispanics (-2.1% per year). In the same period, rates of no usual source of care declined only among Hispanics (-1.2% per year) while rates of foregone/delayed medical care due to cost decreased for all. No substantial changes were observed from 2016-2018 in any outcome across subgroups. Compared with 1999, in 2018 the rates of foregone/delayed medical care due to cost were higher for all (+3.1% among Whites, +3.1% among Blacks, +0.5% among Asians, and +2.2% among Hispanics) without significant change in gaps; rates of no usual source of care were not significantly different among Whites or Blacks but were lower among Hispanics (-4.9%) and Asians (-6.4%). CONCLUSIONS AND RELEVANCE Insurance coverage increased for all, but millions of individuals remained uninsured or underinsured with increasing rates of unmet medical needs due to cost. Those identifying as non-Hispanic Black and Hispanic continue to experience more barriers to health care services compared with non-Hispanic White individuals. KEY POINTS Question: In the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities?Findings: Using National Health Interview Survey data from 1999-2018, we found that insurance coverage increased across all 4 major race/ethnicity groups. However, rates of unmet medical needs due to cost increased without reducing the respective racial/ethnic disparities, and little-to-no change occurred in rates of individuals who have no usual source of care.Meaning: Despite increased coverage, millions of Americans continued to experience barriers to access to care, which were disproportionately more prevalent among those identifying as Black or Hispanic.
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Affiliation(s)
- César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Dorothy Massey
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Shiwani Mahajan
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amarnath R. Annapureddy
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Brita Roy
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Carley Riley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Karthik Murugiah
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | - Oyere Onuma
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marcella Nunez-Smith
- Equity Research and Innovation Center, General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Howard P. Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Nguyen NH, Khera R, Dulai PS, Boland BS, Ohno-Machado L, Sandborn WJ, Singh S. National Estimates of Financial Hardship From Medical Bills and Cost-related Medication Nonadherence in Patients With Inflammatory Bowel Diseases in the United States. Inflamm Bowel Dis 2020; 27:1068-1078. [PMID: 33051681 PMCID: PMC8205631 DOI: 10.1093/ibd/izaa266] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inflammatory bowel diseases (IBDs) are associated with substantial health care needs. We estimated the national burden and patterns of financial toxicity and its association with unplanned health care utilization in adults with IBD in the United States. METHODS Using the National Health Interview survey (2015), we identified individuals with self-reported IBD and assessed national estimates of financial toxicity across domains of financial hardship due to medical bills, cost-related medication nonadherence (CRN) and adoption of cost-reducing strategies, personal and health-related financial distress (worry about expenses), and health care affordability. We also evaluated the association of financial toxicity with emergency department (ED) utilization. RESULTS Of the estimated 3.1 million adults with IBD in the United States, 23% reported financial hardships due to medical bills, 16% of patients reported CRN, and 31% reported cost-reducing behaviors. Approximately 62% of patients reported personal and/or health-related financial distress, and 10% of patients deemed health care unaffordable. Prevalence of financial toxicity was substantial even in participants with higher education, with private insurance, and belonging to middle/high-income families, highlighting underinsurance. Inflammatory bowel disease was associated with 1.6 to 2.6 times higher odds of financial toxicity across domains compared with patients without IBD. Presence of any marker of financial toxicity was associated with higher ED utilization. CONCLUSIONS One in 4 adults with IBD experiences financial hardship due to medical bills, and 1 in 6 adults reports cost-related medication nonadherence. These financial determinates of health-especially underinsurance-have important implications in the context of value-based care.
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Affiliation(s)
- Nghia H Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA,Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, USA,Address correspondence to: Siddharth Singh, MD, MS, Division of Gastroenterology, Adjunct Assistant Professor of Medicine, University of California San Diego, 9452 Medical Center Drive, ACTRI 1W501, La Jolla, CA 92093, USA. E-mail:
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Khera R, Valero-Elizondo J, Nasir K. Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions. J Am Heart Assoc 2020; 9:e017793. [PMID: 32924728 PMCID: PMC7792407 DOI: 10.1161/jaha.120.017793] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) has posed an increasing burden on Americans and the United States healthcare system for decades. In addition, ASCVD has had a substantial economic impact, with national expenditures for ASCVD projected to increase by over 2.5‐fold from 2015 to 2035. This rapid increase in costs associated with health care for ASCVD has consequences for payers, healthcare providers, and patients. The issues to patients are particularly relevant in recent years, with a growing trend of shifting costs of treatment expenses to patients in various forms, such as high deductibles, copays, and coinsurance. Therefore, the issue of “financial toxicity” of health care is gaining significant attention. The term encapsulates the deleterious impact of healthcare expenditures for patients. This includes the economic burden posed by healthcare costs, but also the unintended consequences it creates in form of barriers to necessary medical care, quality of life as well tradeoffs related to non‐health–related necessities. While the societal impact of rising costs related to ASCVD management have been actively studied and debated in policy circles, there is lack of a comprehensive assessment of the current literature on the financial impact of cost sharing for ASCVD patients and their families. In this review we systematically describe the scope and domains of financial toxicity, the instruments that measure various facets of healthcare‐related financial toxicity, and accentuating factors and consequences on patient health and well‐being. We further identify avenues and potential solutions for clinicians to apply in medical practice to mitigate the burden and consequences of out‐of‐pocket costs for ASCVD patients and their families.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX.,Center for Outcomes Research Houston Methodist Houston TX
| | - Khurram Nasir
- Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine New Haven CT.,Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX.,Center for Outcomes Research Houston Methodist Houston TX
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Grandhi GR, Valero-Elizondo J, Mszar R, Brandt EJ, Annapureddy A, Khera R, Saxena A, Virani SS, Blankstein R, Desai NR, Blaha MJ, Cheema FH, Vahidy FS, Nasir K. Association of cardiovascular risk factor profile and financial hardship from medical bills among non-elderly adults in the United States. Am J Prev Cardiol 2020; 2:100034. [PMID: 34327457 PMCID: PMC8315456 DOI: 10.1016/j.ajpc.2020.100034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/14/2020] [Accepted: 07/03/2020] [Indexed: 11/30/2022] Open
Abstract
Background While optimal cardiovascular risk factor (CRF) profile is associated with lower mortality, morbidity, and healthcare expenditures among individuals with atherosclerotic cardiovascular disease (ASCVD), less is known regarding its impact on financial hardship from medical bills. Therefore, we assessed whether an optimal CRF profile is associated with a lower burden of financial hardship from medical bills and a reduction in cost-related barriers to health. Methods We used a nationally representative sample of adults between 18 and 64 years from the National Health Interview Survey between 2013 and 2017. We assessed ASCVD status and the number of risk factors to categorize the study population into 4 mutually exclusive categories: ASCVD (irrespective of CRF profile) and non-ASCVD with poor, average, and optimal CRF profile. Adjusted logistic regression model was used to determine the association of ASCVD/CRF profile with financial hardship from medical bills and cost-related barriers to health (cost-related medication non-adherence (CRN), foregone/delayed care, and high financial distress). Results We included 119,388 non-elderly adults, representing 189 million individuals annually across the United States. Non-ASCVD/optimal CRF profile individuals had a lower prevalence of financial hardship and an inability paying medical bills when compared with individuals with ASCVD (24% vs 45% and 6% vs 19%, respectively). Among individuals without ASCVD and an optimal CRF profile, the prevalence of each cost-related barrier to health was <50% compared with individuals with ASCVD. Poor/low income and uninsured individuals within non-ASCVD/average CRF profile strata had a lower prevalence of financial hardship and an inability paying medical bills when compared with middle/high income and insured individuals with ASCVD. Non-ASCVD individuals with optimal CRF profile had the lowest odds of all barriers to health. Conclusion Optimal CRF profile is associated with a lower prevalence of financial hardship from medical bills and cost-related barriers to health despite lower income and lack of insurance.
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Affiliation(s)
- Gowtham R Grandhi
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention & Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.,Center for Outcomes Research, Houston Methodist, Houston, TX, USA
| | - Reed Mszar
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.,Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Eric J Brandt
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Amarnath Annapureddy
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anshul Saxena
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
| | - Salim S Virani
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Ron Blankstein
- Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA.,Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Faisal H Cheema
- University of Houston College of Medicine, Houston, TX, USA.,HCA Research Institute, Nashville, TN, USA
| | - Farhaan S Vahidy
- Center for Outcomes Research, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention & Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.,Center for Outcomes Research, Houston Methodist, Houston, TX, USA
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Mszar R, Grandhi GR, Valero-Elizondo J, Caraballo C, Khera R, Desai N, Virani SS, Blankstein R, Blaha MJ, Nasir K. Cumulative Burden of Financial Hardship From Medical Bills Across the Spectrum of Diabetes Mellitus and Atherosclerotic Cardiovascular Disease Among Non-Elderly Adults in the United States. J Am Heart Assoc 2020; 9:e015523. [PMID: 32394783 PMCID: PMC7660844 DOI: 10.1161/jaha.119.015523] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD) has a strong association with diabetes mellitus (DM), accounting for approximately two thirds of deaths in this patient population. Many individuals with ASCVD and DM are vulnerable to financial hardship associated with treatment-related expenses. Therefore, we examined the burden of financial hardship from medical bills across the spectrum of ASCVD status with and without DM. Methods and Results Using data from the National Health Interview Survey from 2013 to 2017, we used logistic regression analysis to examine the association of ASCVD and DM status with financial hardship and an inability to pay medical bills from a representative sample of non-elderly adults in the United States. Our study population consisted of 121 672 individuals. Approximately 3.1% of the weighted population had ASCVD, 5.6% had DM, and 1.3% had both ASCVD and DM. Nearly 50% of individuals with ASCVD and DM reported financial hardship from medical bills (23% being unable to pay medical bills at all), whereas ≈28% of those with neither ASCVD nor DM reported financial hardship from medical bills (8% being unable to pay medical bills at all). Individuals with concurrent ASCVD and DM had the highest relative odds of expressing an inability to pay at all when compared with those with neither condition (odds ratio, 2.69; 95% CI, 2.21-3.28). Conclusions Individuals with concurrent ASCVD and DM are at a disproportionately high risk of being unable to pay their medical bills. The findings provide strong evidence for developing more effective public health policies that protect vulnerable populations from financial hardship.
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Affiliation(s)
- Reed Mszar
- Department of Chronic Disease Epidemiology Yale School of Public Health New Haven CT.,Center for Outcomes Research and Evaluation Yale New Haven Health New Haven CT
| | | | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - César Caraballo
- Center for Outcomes Research and Evaluation Yale New Haven Health New Haven CT
| | - Rohan Khera
- University of Texas Southwestern Medical Center Dallas TX
| | - Nihar Desai
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Salim S Virani
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Houston TX
| | | | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease Baltimore MD
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX
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