Mobile Application to Identify Cancer Treatment-Related Financial Assistance: Results of a Randomized Controlled Trial

PURPOSE

Insured patients with cancer face high treatment-related, out-of-pocket (OOP) costs and often cannot access financial assistance. We conducted a randomized, controlled trial of Bridge, a patient-facing app designed to identify eligible financial resources for patients. We hypothesized that patients using Bridge would experience greater OOP cost reduction than controls.

METHODS

We enrolled patients with cancer who had OOP expenses from January 2018 to March 2019. We randomly assigned patients 1:1 to intervention (Bridge) versus control (financial assistance educational websites). Primary and secondary outcomes were self-reported OOP costs and subjective financial distress 3 months postenrollment. In post hoc analyses, we analyzed application for and receipt of financial assistance at 3 months postenrollment. We used chi-square, Mann-Whitney tests, and logistic regression to compare study arms.

RESULTS

We enrolled 200 patients. The median age was 57 years (IQR, 47.0-63.0). Most patients had private insurance (71%), and the median household income was $62,000 in US dollars (USD) (IQR, $36,000-$100,000 [USD]). Substantial missing data precluded assessment of primary and secondary outcomes. In post hoc analyses, patients in the Bridge arm were more likely than controls to both apply for and receive financial assistance.

CONCLUSION

We were unable to test our primary outcome because of excessive missing follow-up survey data. In exploratory post hoc analyses, patients who received a financial assistance app were more likely to apply for and receive financial assistance. Ultimately, our study highlights challenges faced in identifying measurable outcomes and retaining participants in a randomized, controlled trial of a mobile app to alleviate financial toxicity.

Does Cancer Treatment-Related Financial Distress Worsen Over Time?

BACKGROUND Patients with cancer are at risk for both objective and subjective financial distress. Financial distress during treatment is adversely associated with physical and mental well-being. Little is known about whether patients' subjective financial distress changes during the course of their treatment.method This is a cross-sectional study of insured adults with solid tumors on anti-cancer therapy for ≥1 month, surveyed at a referral center and three rural oncology clinics. The goal was to investigate how financial distress varies depending on where patients are in the course of cancer therapy. Financial distress (FD) was assessed via a validated measure; out-of-pocket (OOP) costs were estimated and medical records were reviewed for disease/treatment data. Logistic regression was used to evaluate the potential association between treatment length and financial distress.RESULTS Among 300 participants (86% response rate), median age was 60 years (range 27-91), 52.3% were male, 78.3% had stage IV cancer or metastatic recurrence, 36.7% were retired, and 56% had private insurance. Median income was $60,000/year and median OOP costs including insurance premiums were $592/month. Median FD score (7.4/10, SD 2.5) corresponded to low FD with 16.3% reporting high/overwhelming distress. Treatment duration was not associated with the odds of experiencing high/overwhelming FD in single-predictor (OR = 1.01, CI [.93, 1.09], P = .86) or multiple predictor regression models (OR = .98, CI [.86, 1.12], P = .79). Treatment duration was not correlated with FD as a continuous variable (P = .92).LIMITATIONS This study is limited by its cross-sectional design and generalizability to patients with early-stage cancer and those being treated outside of a major referral center.CONCLUSION Severity of cancer treatment-related financial distress did not correlate with time on treatment, indicating that patients are at risk for FD throughout the treatment continuum. Screening for and addressing financial distress should occur throughout the course of cancer therapy.

A randomized controlled trial (RCT) testing a mobile application (app) to identify cancer treatment-related financial assistance

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Background: Insured cancer patients face high treatment-related, out-of-pocket costs. While philanthropic- and pharmaceutical-sponsored financial assistance programs exist, patients are often unaware of them. We developed “Bridge”, a patient-facing app that identified financial assistance programs for which a patient might be eligible based on treatment, disease, insurance, and financial characteristics. We hypothesized that patients in the Bridge study arm would be more likely than controls to apply for and receive financial assistance. Methods: We enrolled patients at a single institution from January 2018-March 2019. Patients were receiving treatment for any cancer, had a life expectancy of ≥6 months, and self-reported out-of-pocket costs. We randomized patients 1:1 to intervention (Bridge) vs. control (financial assistance educational websites). We assessed subjective financial distress with the validated COST measure. Outcomes included application for and receipt of financial assistance. Data on outcomes was collected from the medical record, institutional pharmacy database, and Bridge. We compared patient characteristics between study arms using chi-square and Mann-Whitney-Wilcoxon tests. We used an unadjusted logistic regression model to compare differences in outcomes. Results: We randomized 200 patients and found no significant differences between arms in baseline characteristics (Table). At 6 months from enrollment, patients in the Bridge arm were more likely than controls to apply for financial assistance [35% Bridge vs. 10% control, OR 3.53, 95%CI 1.69-7.34, p < 0.01]. Bridge patients were also more likely than controls to receive financial assistance (30% Bridge vs. 9% control, OR 3.39, 95%CI 1.78-6.46, p < 0.01). Conclusions: Among patients with treatment-related out-of-pocket costs, those who interacted with a financial assistance app were significantly more likely to apply for and receive treatment-related financial assistance. [Table: see text]

The need for a Serious Illness Digital Ecosystem (SIDE) to improve outcomes for patients receiving palliative and hospice care

Palliative and hospice care services produce immense benefits for patients living with serious illness and for their families. Due to the national shift toward value-based payment models, health systems and payers share a heightened awareness of the need to incorporate palliative and hospice services into their service mix for seriously ill patient populations. During the last decade, a tremendous amount of capital has been invested to better integrate information technology into healthcare. This includes development of technologies to promote utilization of palliative and hospice services. However, no coordinated strategy exists to link such efforts together to create a cohesive strategy that transitions from identification of patients through receipt of services. A Serious Illness Digital Ecosystem (SIDE) is the intentional aggregation of disparate digital and mobile health technologies into a single system that connects all of the actors involved in serious illness patient care. A SIDE leverages deployed health technologies across disease continuums and geographic locations of care to facilitate the flow of information among patients, providers, health systems, and payers. Five pillars constitute a SIDE, and each one is critical to the success of the system. The 5 pillars of a SIDE are: Identification, Education, Engagement, Service Delivery, and Remote Monitoring. As information technology continues to evolve and becomes a part of the care delivery landscape, it is necessary to develop cohesive ecosystems that inform all parts of the serious illness patient experience and identifies patients for the right services, at the right time.

Going for Broke: A Longitudinal Study of Patient-Reported Financial Sacrifice in Cancer Care

PURPOSE

Patients with cancer are at risk for substantial treatment-related costs; however, little is known about patients' willingness to sacrifice to receive cancer care and how their attitudes and burden may change with time.

PATIENTS AND METHODS

We conducted a longitudinal survey of insured patients with solid tumor cancers receiving chemotherapy or hormonal therapy. Patients were surveyed at two time points about their willingness to make financial sacrifices and their actual sacrifices, including out-of-pocket costs. Patient attitudes and sacrifices were compared over time.

RESULTS

Of 349 patients approached, 300 completed the baseline survey (86% response) and 245 completed the follow-up survey 3 months later (82% retention). Median patient-reported cancer-related out-of-pocket costs for patients who completed both surveys were $393 per month (range, $0 to $26,586 per month) at baseline and $328 per month (range, $0 to $8,210 per month) at follow-up. At baseline, 49% were willing to declare personal bankruptcy, 38% were willing to sell their homes, and ≥ 65% were willing to make other sacrifices, including borrowing money to afford their cancer care. Upon follow-up, there were minor decreases in willingness; the maximum net change was a 7% decline in patients willing to declare bankruptcy. Actual sacrifice increased over time; the greatest increase was in patients who used their savings (increased from 41% to 54%).

CONCLUSION

A large proportion of insured patients with cancer were willing to make considerable personal and financial sacrifices to receive care; these attitudes did not change greatly over time. Shared decision making is important to ensure patients fully understand the goals, risks, and benefits of therapy before they make such personal sacrifices.

Feasibility and Acceptability of a Best Supportive Care Checklist among Clinicians

CONTEXT

Best supportive care (BSC) is often not standardized across sites, consistent with best evidence, or sufficiently described. We developed a consensus-based checklist to document BSC delivery, including symptom management, decision making, and care planning. We hypothesized that BSC can be feasibly documented with this checklist consistent with consolidated standards of reporting trials.

OBJECTIVE

To determine feasibility/acceptability of a BSC checklist among clinicians.

METHODS

To test feasibility of a BSC checklist in standard care, we enrolled a sample of clinicians treating patients with advanced cancer at four centers. Clinicians were asked to complete the checklist at eligible patient encounters. We surveyed enrollees regarding checklist use generating descriptive statistics and frequencies.

RESULTS

We surveyed 15 clinicians and 9 advanced practice providers. Mean age was 41 (SD = 7.9). Mean years since fellowship for physicians was 7.2 (SD = 4.5). Represented specialties are medical oncology (n = 8), gynecologic oncology (n = 4), palliative care (n = 2), and other (n = 1). For "overall impact on your delivery of supportive/palliative care," 40% noted improved impact with using BSC. For "overall impact on your documentation of supportive/palliative care," 46% noted improvement. Impact on "frequency of comprehensive symptom assessment" was noted to be "increased" by 33% of providers. None noted decreased frequency or worsening impact on any measure with use of BSC. Regarding feasibility of integrating the checklist into workflow, 73% agreed/strongly agreed that checklists could be easily integrated, 73% saw value in integration, and 80% found it easy to use.

CONCLUSION

Clinicians viewed the BSC checklist favorably illustrating proof of concept, minor workflow impact, and potential of benefit to patients.

Delivery of Community-Based Palliative Care: Findings from a Time and Motion Study

Background: Use of palliative care has increased substantially as the population ages and as evidence for its benefits grows. However, there is limited information regarding which care activities are necessary for delivering high-quality, interdisciplinary, community-based palliative care.

Objectives: This study aims to identify and measure the discrete clinical and administrative activities completed by a multidisciplinary team in a hospice provider-led model for providing community-based palliative care.

Study Design: A time and motion study was conducted at three care settings within a large hospice and palliative care network and a process map was drawn to describe the personnel and activities recorded.

Methods: Researchers recorded activities performed by clinical and administrative staff. Activities were categorized into those related to patient care, administrative duties, care coordination, and other. A process map of palliative care delivery was created and descriptive statistics were used to calculate the proportion of time spent on discrete activities and within each activity category.

Results: Over 50 hours of activities were recorded during which the clinicians interacted with 25 patients and engaged in 20 distinct tasks. Physicians spent 94% of their time on tasks related to patient care and 1% on administrative tasks. Nurse practitioners and registered nurses spent 82% and 53% of their time on patient-related tasks and 2% and 37% on administrative tasks, respectively.

Conclusion: The delivery of palliative care is interdisciplinary and involves numerous discrete tasks and activities. Understanding the components of a community-based palliative care model is the first step to designing incentives to encourage its spread.

Bridging the financial assistance gap: A pilot study of a patient-facing app to identify drug financial assistance programs

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Background: Many cancer patients face high treatment-related costs and are often unaware of available financial resources. We designed “Bridge” as a stand-alone, smartphone app to reduce out-of-pocket treatment costs by connecting patients to tailored financial assistance programs. The goal of this pilot study was to evaluate the usability and preliminary effectiveness of Bridge. Methods: Eligible cancer patients were receiving anti-cancer treatment, owned a smartphone, and reported out-of-pocket treatment-related costs. Patients interacted with Bridge, inputted personal and financial data, and reviewed personalized financial resource results. Usability was assessed via the validated System Usability Scale (SUS). To be usable, patients would have to score at least 68 on the SUS. Effectiveness was assessed by two measures: “Bridge improved my knowledge about financial aspects of cancer care and what can be done about it” (1 = strongly disagree to 5 = strongly agree) and “Using this tool was helpful with my financial concerns” (1 = strongly disagree to 5 = strongly agree). Results: We enrolled 30 patients. 63% were female, 23% were non-white, 66% had greater than high school education, 97% were insured (48% Medicare), and 23% were employed. Median annual household income was $60,796. All patients completed a full interaction with the app, with median time to results of 116 seconds. 72% of patients matched to at least one currently open program, with patients matching to a median of 4 financial assistance programs. 90% of patients reported an SUS score of usable (i.e., > 68 out of 100). The median SUS score was 85. 83% of patients agreed or strongly agreed that “Bridge improved my knowledge about financial aspects of cancer care and what can be done about it.” 53% of patients agreed or strongly agreed that “Using this website was helpful with my financial concerns.” Conclusions: We found that patients rated Bridge as usable and acceptable. We also found that Bridge helped match most patients to relevant assistance programs and improved knowledge about financial aspects of cancer care. The next phase of this NCI-funded study will test the effectiveness of Bridge in a large, randomized, controlled trial.

Feasibility and acceptability of a best supportive care (BSC) checklist among clinicians

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Background: Some clinical trials for advanced cancer compare experimental therapy to BSC. Usually BSC is not standardized across sites, consistent with best available evidence in palliative care practice, or described in sufficient detail. We developed a consensus-based checklist to document BSC delivery, including symptom management, decision making, and care planning. We hypothesized that BSC can be feasibly documented with this checklist consistent with Consolidated Standards Of Reporting Trials (CONSORT) statements. Methods: Clinicians at 4 academic centers were asked to complete the BSC checklist at each encounter with eligible cancer patients. Enrolled physicians completed a survey regarding use of the checklist during clinic appointments. Descriptive statistics and frequencies were generated. Results: 15 clinicians completed the checklist survey, 9 of whom were advanced practice providers. Mean age was 41 (SD = 7.9). Mean number of years in practice since fellowship for physicians was 7.2 (SD = 4.5). Represented were medical oncology (n = 8), gynecologic oncology (n = 4), palliative care (n = 2), and other (n = 1). For “overall impact on your delivery of supportive/palliative care,” 40% noted improved impact with the checklist. For “overall impact on your documentation of supportive/palliative care,” 46% noted improvement. Impact on “frequency of comprehensive symptom assessment” was 33% “increased.” Impact on “frequency with which you assessed for referral to support services” was 26% “increased.” Impact on “frequency with which you educated patients regarding goals of therapy” was 20% “increased.” No one noted decreased frequency or worsening impact. Regarding feasibility of integrating BSC in workflow, 73% agreed or strongly agreed that the BSC checklist could be easily integrated; 73% saw value in integration; and 80% found it easy to use. Conclusions: Clinicians viewed the BSC checklist favorably. While a small sample, this illustrates proof of concept, minor impact on provider workflow, and potential benefit to patients for use in a future randomized trial.

Empowering patients to self-identify financial assistance programs using an online application

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Background: Available financial resources are relatively unknown to many patients with cancer facing high treatment-related costs. PAPNavigator is a web-based app designed to reduce out-of-pocket treatment costs by connecting patients to financial assistance programs specific to them. Traditionally used by financial counselors, PAPNavigator was modified to be patient-facing for this study, testing preliminary usability and effectiveness. Methods: Eligible patients with cancer were receiving anti-cancer treatment and reported out-of-pocket treatment costs. Patients interacted with PAPNavigator, inputted personal and financial data, and reviewed personalized financial resource results. Usability was assessed via the validated System Usability Scale (SUS). Effectiveness was assessed by two measures: “PAPNavigator improved my knowledge about financial aspects of cancer care and what can be done about it” and “Using this website was helpful with my financial concerns.” For all items, patients responded using a 5-point Likert scale. Results: 19 of 20 patients completed pilot testing (95%, 1 withdrew due to illness). 53% of patients were male, 26% were non-white, 79% had greater than a high school education, and 21% were employed full- or part-time. Median annual household income was $77,500. The median SUS score was 75 out of 100 (with >68 considered above average.) In response to statements, “I think that I would need assistance to be able to use this website,” and “I felt very confident using this website,” the median scores were 2 and 5 respectively. Additionally, in response to the statements, “PAPNavigator improved my knowledge about financial aspects of cancer care and what can be done about it,” and “Using this website was helpful with my financial concerns,” the median score for each was 4. Conclusions: The modified version of PAPNavigator demonstrated high usability and preliminary effectiveness in improving knowledge about financial aspects of cancer care and potential interventions to reduce cost. Further testing in larger samples is necessary.

Usability and Acceptability of the QDACT-PC, an Electronic Point-of-Care System for Standardized Quality Monitoring in Palliative Care

CONTEXT

Few resources exist to support collaborative quality monitoring in palliative care. These tools, if proven efficient through technology-enabled methods, may begin to routinize data collection on quality during usual palliative care delivery. Usability testing is a common approach to assess how easily and effectively users can interact with a newly developed tool.

OBJECTIVES

We performed usability testing of the Quality Data Collection Tool for Palliative Care (QDACT-PC) a novel, point-of-care quality monitoring tool for palliative care.

METHODS

We used a mixed methods approach to assess community palliative care clinicians' evaluations of five domains of usability. These approaches included clinician surveys after recording mock patient data to assess satisfaction; review of entered data for accuracy and time to completion; and thematic review of "think aloud" protocols to determine issues, barriers, and advantages to the electronic system.

RESULTS

We enrolled 14 palliative care clinicians for the study. Testing the electronic system vs. paper-based methods demonstrated similar error rates and time to completion. Overall, 68% of the participants believed that the electronic interface would not pose a moderate or major burden during usual clinical activities, and 65% thought it would improve the care they provided. Thematic analysis revealed significant issues with paper-based methods alongside training needs for future participants on using novel technologies that support the QDACT-PC.

CONCLUSION

The QDACT-PC is a usable electronic system for quality monitoring in palliative care. Testing reveals equivalence with paper for data collection time, but with less burden overall for electronic methods across other domains of usability.

The utility of cost discussions between patients with cancer and oncologists

OBJECTIVES

Patients with cancer can experience substantial financial burden. Little is known about patients' preferences for incorporating cost discussions into treatment decision making or about the ramifications of those discussions. The objective of this study was to determine patient preferences for and benefits of discussing costs with doctors.

STUDY DESIGN

Cross-sectional, survey study.

METHODS

We enrolled insured adults with solid tumors on anticancer therapy who were treated at a referral cancer center or an affiliated rural cancer clinic. Patients were surveyed at enrollment and again 3 months later about cost discussions with doctors, decision making, and financial burden. Medical records were abstracted for disease and treatment data. Logistic regression investigated characteristics associated with greater desire to discuss costs.

RESULTS

Of 300 patients (86% response rate), 52% expressed some desire to discuss treatment-related out-of-pocket costs with doctors and 51% wanted their doctor to take costs into account to some degree when making treatment decisions. However, only 19% had talked to their doctor about costs. Of those, 57% reported lower out-of-pocket costs as a result of cost discussions. In multivariable logistic regression, higher subjective financial distress was associated with greater likelihood to desire cost discussions (odds ratio [OR], 1.22; 95% CI, 1.10-1.36). Nonwhite race was associated with lower likelihood to desire cost discussions (OR, 0.53; 95% CI, 0.30-0.95).

CONCLUSIONS

Patients with cancer varied in their desire to discuss costs with doctors, but most who discussed costs believed the conversations helped reduce their expenses. Patient-physician cost communication might reduce out-of-pocket costs even in oncology where treatment options are limited.

Development and validation of a patient-reported tool to evaluate legal and financial needs in patients with advanced cancer

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Background: Cancer patients frequently report problems with finances, housing, advance care planning, and work-related issues. Because of these complex legal needs, cancer centers are developing Medical-Legal Programs (MLP) to connect referred patients with legal professionals. These programs lack validated screening methods to target services to those with the greatest legal distress. To date, no validated, patient-reported measure to assess the portfolio of legal needs has been developed for patients with cancer. Methods: We developed the Cancer Legal Screener to address five common domains within MLP practice: Housing; Income and Insurance; Employment; Family Stability; and Legal Status and General concerns. The 15 questions were then reviewed in two rounds for face validity by two of each: social workers, oncologists, palliative care physicians, attorneys, and lay persons. After two iterative updates, we piloted the screener in our palliative care and gastrointestinal malignancies clinics for six months. After participants completed the screener, they responded to a 10-item survey rating three areas: Consent/Presentation, Ease of Use, and Value to Care. Each question was measured on a 5-point Likert scale. Scores were weighted one through five and averages calculated. Results: We received scores from 79 patients. Their median age was 61 years; 39% were female, 29% were African-American. Regarding socioeconomic status, 75% had completed at least some college and 53% reported having an income level ≤ $50,000. During patient-reported validation testing, all 10 items across the three domains satisfied the feasibility criteria with average weighted satisfaction scores ranging from 3.22-3.89. Of patients surveyed, most indicated “Agree” or “Strongly Agree” regarding understandability of included questions (84%), prompts being “easy to follow” (81%), and “this form may help my doctors deliver better care” (63%). Conclusions: We have developed and validated one of the first patient-reported tools to assess medical-legal needs in patients with cancer. Future research will test triage models to target the appropriate legal resources to patients with the greatest legal needs.

Formation of an international quality improvement collaborative for palliative care: The Global Palliative Care Quality Alliance (GPCQA)

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Background: Formal mechanisms to share data on quality remain immature in specialty palliative care. As the field grows, infrastructure that promotes collaboration among academic and community-based practice will be required to foster comparisons and benchmarking of data to inform areas for quality improvement. Further, such relationships will create a palliative care “quality improvement laboratory”, where proposed guidelines and best practices can be developed, implemented, and tested. Methods: We set out to bring together specialty palliative care practices with a shared vision for collaborative quality improvement. We modeled our approach after the Institute for Healthcare Improvement Breakthrough Series alongside our Rapid Learning Quality Improvement paradigm. We use a set of common data collection procedures, across an electronic point-of-care platform called Quality Data Collection Tool (QDACT), alongside a centralized data registry. Further, we meet and discuss challenges and issues, compare best practices, and brainstorm new projects through biweekly conference calls. Results: We have created a multi-institutional collaboration for quality assessment and improvement in specialty palliative care. Termed the Global Palliative Care Quality Alliance, we have brought together 11 academic and community organizations, both general and oncology-specific, across six states to study various areas of quality practice. Short-term, we will conduct rapid-cycling quality improvement projects addressing National Quality Forum domains for quality palliative care, including documentation of spiritual assessment and timely advance care planning. Long-term, we aim to study the link between quality measure adherence and outcomes and further align our initiatives with those of other large consortia, like the Palliative Care Research Cooperative and Palliative Care Quality Network. Conclusions: Collaborative quality improvement is needed in specialty palliative care across a national platform. Developing the infrastructure to perform standardized quality improvement is achievable across multiple palliative care settings.

Bridging the gap between financial distress and available resources for patients with cancer: a qualitative study

PURPOSE

Cancer treatment-related out-of-pocket costs create substantial financial distress for many patients. However, little work has been done to describe available financial resources and barriers to connecting those resources to patients.

METHODS

This was a single-center, qualitative study that used semistructured interviews and focus groups with social workers and financial care counselors. Interview guides were used to elicit feedback from study participants pertaining to the types of financial problems that their patients were experiencing, the process for addressing these issues, patient assistance resources, and access barriers.

RESULTS

Four interviews and two focus group sessions (n = 15) were conducted in which four themes emerged among the social work and financial care counselor samples. Participants cited (1) frustration over the lack of financial resources and increasingly stringent eligibility criteria, (2) barriers to providing assistance such as process inefficiencies, (3) limited resources to identify at- risk patients and refer them for services, and (4) inadequate insurance coverage and availability. To bridge the gap between increasing patient need and limited resources, participants suggested development of interventions designed to aid in patient screening and resource identification.

CONCLUSIONS

Oncology social workers and financial care counselors reported inadequate financial resources and faced barriers to matching appropriate resources with patients in need. Limited social work resources hindered early screening for financial distress. Interventions that focus on screening for early identification of financial distress and identification of resources are needed.

What type of feedback to clinicians best improves conformance to supportive care quality measures?

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Background: Supportive care is under-addressed in oncology and an important area for quality improvement. Regular, directed feedback is an important component of effective quality management. What type of feedback yields the highest conformance to supportive care measures? Methods: Within the Carolinas Palliative Care Consortium, we conducted a series of three PDSA cycles, each one month-long, to evaluate various types of clinician-directed feedback on conformance to two supportive care measures. We collected data using a web-based, mobile health platform called QDACT-PC (Quality Data Collection Tool for Palliative Care). Every four weeks, feedback to clinicians on performance was changed in a stepwise fashion, from “no feedback” to “personal feedback” to “comparative feedback” (personal conformance compared to the rest of the Consortium). We monitored weekly changes to conformance to two quality measures: documentation of timely management of constipation and dyspnea. To meet the measures, symptoms with intensity of >3/10 on the Edmonton Symptom Assessment Scale required documentation of intervention within 24 hours. Conformance rates were calculated and compared to a historical baseline. Results: 23 providers participated in this quality improvement project, which spanned 465 patient encounters across 104 unique patients. Baseline data generated from 3/2008-10/2011 demonstrated baseline conformance to the dyspnea and constipation measures at 6% (27/457) and 4% (14/398), respectively. After addition of an electronic, prospective quality monitoring system alone (QDACT-PC), conformance increased to 93% (42/45) and 92% (23/25), respectively. With personalized, weekly feedback, these rates increased to 94% for dyspnea and 100% for constipation. Feedback comparing personal performance to the average of the rest of the Consortium further increased this to 100% for both. Conclusions: Regular, weekly feedback on performance increases conformance to supportive care quality measures. Adding comparative feedback versus other peers solidifies this effect. Duration of the effect is being evaluated.

Patient-oncologist cost communication, financial distress, and medication adherence

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Background: Little is known about the association between patient-oncologist discussion of cancer treatment out-of-pocket (OOP) cost and medication adherence, a critical component of quality cancer care. Methods: We conducted a cross-sectional survey of insured adults receiving anti-cancer therapy. Patients were asked if they had discussed OOP cost with their oncologist. Medication non-adherence was defined as skipping doses to make prescriptions last longer, taking less medication than prescribed to make prescriptions last longer, or not filling prescriptions due to cost. Multivariable analysis assessed the association between cost discussions with an oncologist and non-adherence. Results: Among 300 respondents (84% response), 77% (n=230) were white and 53% (n=158) were men. 17% (n=52) reported “high” or “overwhelming” financial distress. 19% (n=56) had talked to their oncologist about cost. 27% (n=81) reported medication non-adherence. 14% (n=43) skipped medication doses to make the prescription last longer; 7% (n=3) of these had skipped chemotherapy. 11% (n=34) took less medication than prescribed to make the prescription last longer; 15% (n=5) of these took less chemotherapy. 22% (n=67) did not fill a prescription because of cost; 15% (n=10) of these did not fill a chemotherapy prescription. In adjusted analyses, cost discussion (OR 2.56, 95% CI 1.15-5.68; p=0.02), financial distress (OR 1.57, 95% CI 1.33-1.85, P<0.001) and female gender (OR 2.02, 95% CI 1.005-4.07, p=0.048) were associated with increased odds of non-adherence. Private insurance was associated with lower odds of non-adherence (OR 0.30, 95% CI 0.14-0.60, p<0.001). Conclusions: Patients reported non-adherence to medications and chemotherapy in order to make prescriptions last longer or due to cost. While these data cannot determine temporality or the affect of cost discussion on medication non-adherence, patient-oncologist cost communication and financial distress were associated with non-adherence. Future research should examine the timing, content, and quality of cost-related discussions.

The financial burden of cancer care: Do patients know what to expect?

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Background: Patients receiving cancer treatment can experience significant financial distress (FD), but little is known about whether patients are adequately informed about costs of care. Methods: This is a planned interim analysis of an ongoing cross-sectional study of insured adults with solid tumors on anticancer therapy for ≥1 month. Consecutive patients were surveyed, in person, at a referral center and 3 rural oncology clinics. Participants were asked about subjective FD (via validated measure), out-of-pocket costs, expected burden, and willingness to accept high out-of-pocket costs. Medical records were reviewed for disease and treatment data. Logistic regression assessed the relationship between FD, expected burden, quality of life (QOL), and willingness to accept high out-of-pocket costs. Results: Among 119 participants (85% response), median age was 60 years (range 27-86), 54% were men, 29% were non-white, 96% had completed high school, and 40% were retired. 81% had incurable cancer. Median income was $50,000/yr. Median out-of-pocket costs were $480/mo. 19% reported high/overwhelming FD. Median time on treatment was 200 days. Compared to anticipated levels of personal financial burden at the start of treatment, 40% were experiencing a higher degree of burden, 24% were experiencing a lower degree of burden, and 32% were experiencing the same degree of burden. In adjusted analyses, both high/overwhelming FD score (OR 4.79; 95% CI 1.64-13.95; p=0.004) and a lower QOL score (OR 0.81; 95% CI 0.67-0.99; p=0.035) were associated with a higher than expected financial burden. The following were not associated with higher than expected financial burden: age, gender, education, cancer stage, cost as a proportion of income, time on treatment, or willingness to accept high out-of-pocket costs. Conclusions: A large portion of insured patients faced out-of-pocket costs that were greater than expected. Those who were least prepared for financial burden reported higher FD and lower QOL. Since patient characteristics could not identify those at highest risk for unexpected cost burden, future research should focus on how to identify patients at risk and better prepare them for potential treatment-related financial burden.

Financial distress, communication, and cancer treatment decision making: Does cost matter?

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Background: Financial distress (FD) increases the burden of living with cancer. Even insured patients may experience considerable FD, but little is known about whether patients want to include cost discussions in treatment decision-making. Methods: This is an ongoing cross-sectional study of insured adults with solid tumors on anticancer therapy for ≥1 month. Consecutive patients were surveyed, in person, at a referral center and 3 rural oncology clinics. Participants were asked about FD (via a validated measure), out-of-pocket (OOP) costs, discussion of costs with their doctor, and decision-making. Medical records were reviewed for disease and treatment data. Logistic regression assessed the relationship between FD and cost communication. Results: 119 participants (85% response) had a median age of 60 years (range 27-86). 54% were men, 29% non-white, and 96% completed high school. 81% had incurable cancer. 58% had private insurance. Median income was $50,000/yr. Median OOP costs were $480/mo. The mean FD score (6.7, SD 2.5) corresponded to moderate FD. 19% reported high/overwhelming FD. Overall, 48% (n=57) expressed any desire to discuss costs with their doctor, but only 21% (n=25) had actually done so. Of the 19% with highest FD, 36% (n=8) had discussed costs with a doctor, and 68% (n=15) expressed any desire to discuss costs. The most common reasons for not discussing costs with doctors were: “no problems with costs” (n=47); “want best care regardless of cost” (n=36); and “doctors shouldn’t have to worry about costs” (n=19). Of those who discussed costs with their doctor, 48% (n=12) felt the discussion helped decrease costs. 54% (n=64) wanted their doctors to account for costs in cancer treatment decision-making; 20% (n=24) always wanted costs considered in decision-making. High FD was the only variable associated with greater willingness to discuss costs (adjusted OR 2.81; 95%CI 1.05-7.50; p=0.04). Conclusions: FD was prevalent among insured cancer patients. A large proportion wanted costs discussed with doctors and included in treatment decision-making. Discussing finances may lower costs, but the discussion rarely occurs. Communication and decision-making present a potential focus for intervening on FD.