1
|
Vadlakonda A, Cho NY, Chervu N, Porter G, Curry J, Sakowitz S, Coaston T, Rook JM, Juillard C, Benharash P. Association of uninsured status and rurality with risk of financial toxicity after pediatric trauma. Surgery 2024; 176:455-461. [PMID: 38772775 DOI: 10.1016/j.surg.2024.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/18/2024] [Accepted: 12/14/2023] [Indexed: 05/23/2024]
Abstract
BACKGROUND Pediatric traumatic injury is associated with long-term morbidity as well as substantial economic burden. Prior work has labeled the catastrophic out-of-pocket medical expenses borne by patients as financial toxicity. We hypothesized uninsured rural patients to be vulnerable to exorbitant costs and thus at greatest risk of financial toxicity. METHODS Pediatric patients (<18 years) experiencing traumatic injury were identified in the 2016-2019 National Inpatient Sample. Patients were considered to be at risk of financial toxicity if their hospitalization cost exceeded 40% of post-subsistence income. Individual family income was computed using a gamma distribution probability density function with parameters derived from publicly available US Census Bureau data, in accordance with prior work. A multivariable logistic regression was developed to assess factors associated with risk of financial toxicity. RESULTS Of an estimated 225,265 children identified for study, 34,395 (15.3%) were Rural. Rural patients were more likely to experience risk of financial toxicity (29.1 vs 22.2%, P < .001) compared to Urban patients. After adjustment, rurality (reference: urban status; adjusted odds ratio 1.45, 95% confidence interval 1.36-1.55) and uninsured status (reference: private; adjusted odds ratio 1.85, 95% confidence interval 1.67-2.05) remained linked to increased odds of risk of financial toxicity. Specifically among those with private insurance, Rural patients experienced markedly higher predicted risk of financial toxicity, relative to Urban. CONCLUSION Our findings suggest a complex interplay between rural status and insurance type in the prediction of risk of financial toxicity after pediatric trauma. To target policy interventions, future studies should characterize the patients and communities at greatest risk of financial devastation among rural pediatric trauma patients.
Collapse
Affiliation(s)
- Amulya Vadlakonda
- Department of Surgery, University of California, Los Angeles, CA. https://twitter.com/amulyavad
| | - Nam Yong Cho
- Department of Surgery, University of California, Los Angeles, CA
| | - Nikhil Chervu
- Department of Surgery, University of California, Los Angeles, CA
| | - Giselle Porter
- Department of Surgery, University of California, Los Angeles, CA
| | - Joanna Curry
- Department of Surgery, University of California, Los Angeles, CA
| | - Sara Sakowitz
- Department of Surgery, University of California, Los Angeles, CA
| | - Troy Coaston
- Department of Surgery, University of California, Los Angeles, CA
| | - Jordan M Rook
- Department of Surgery, University of California, Los Angeles, CA; Greater Los Angeles Veterans Administration Healthcare System, Los Angeles CA; National Clinician Scholars Program, University of California, Los Angeles, CA; Fielding School of Public Health, University of California, Los Angeles, CA
| | - Catherine Juillard
- Division of General Surgery (Trauma and Surgical Critical Care Section), University of California, Los Angeles, CA
| | - Peyman Benharash
- Department of Surgery, University of California, Los Angeles, CA.
| |
Collapse
|
2
|
Sankaran R, O'Connor J, Nuliyalu U, Diaz A, Nathan H. Payer-Negotiated Price Variation and Relationship to Surgical Outcomes for the Most Common Cancers at NCI-Designated Cancer Centers. Ann Surg Oncol 2024; 31:4339-4348. [PMID: 38506934 DOI: 10.1245/s10434-024-15150-x] [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: 12/01/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Federal rules mandate that hospitals publish payer-specific negotiated prices for all services. Little is known about variation in payer-negotiated prices for surgical oncology services or their relationship to clinical outcomes. We assessed variation in payer-negotiated prices associated with surgical care for common cancers at National Cancer Institute (NCI)-designated cancer centers and determined the effect of increasing payer-negotiated prices on the odds of morbidity and mortality. MATERIALS AND METHODS A cross-sectional analysis of 63 NCI-designated cancer center websites was employed to assess variation in payer-negotiated prices. A retrospective cohort study of 15,013 Medicare beneficiaries undergoing surgery for colon, pancreas, or lung cancers at an NCI-designated cancer center between 2014 and 2018 was conducted to determine the relationship between payer-negotiated prices and clinical outcomes. The primary outcome was the effect of median payer-negotiated price on odds of a composite outcome of 30 days mortality and serious postoperative complications for each cancer cohort. RESULTS Within-center prices differed by up to 48.8-fold, and between-center prices differed by up to 675-fold after accounting for geographic variation in costs of providing care. Among the 15,013 patients discharged from 20 different NCI-designated cancer centers, the effect of normalized median payer-negotiated price on the composite outcome was clinically negligible, but statistically significantly positive for colon [aOR 1.0094 (95% CI 1.0051-1.0138)], lung [aOR 1.0145 (1.0083-1.0206)], and pancreas [aOR 1.0080 (1.0040-1.0120)] cancer cohorts. CONCLUSIONS Payer-negotiated prices are statistically significantly but not clinically meaningfully related to morbidity and mortality for the surgical treatment of common cancers. Higher payer-negotiated prices are likely due to factors other than clinical quality.
Collapse
Affiliation(s)
- Roshun Sankaran
- University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Radiology, University of California San Diego, San Diego, CA, USA
| | - John O'Connor
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
- IHPI Clinician Scholars Program, Ann Arbor, MI, USA
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA.
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
3
|
Rashid Z, Munir MM, Woldesenbet S, Khalil M, Katayama E, Khan MMM, Endo Y, Altaf A, Tsai S, Dillhoff M, Pawlik TM. Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy. J Gastrointest Surg 2024; 28:1137-1144. [PMID: 38762337 DOI: 10.1016/j.gassur.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/20/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.
Collapse
Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States.
| |
Collapse
|
4
|
Hirata Y, To C, Lyu H, Smith GL, Samuel JP, Tran Cao HS, Badgwell BD, Katz MHG, Ikoma N. Prevalence of and Factors Associated with Financial Toxicity After Pancreatectomy and Gastrectomy. Ann Surg Oncol 2024; 31:4361-4370. [PMID: 38536586 DOI: 10.1245/s10434-024-15236-6] [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: 12/27/2023] [Accepted: 03/12/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Financial toxicity (FT) refers to the adverse impact of cancer treatment costs on patients' experiences, potentially leading to poor adherence to treatment and outcomes. However, the prevalence of FT among patients undergoing major upper gastrointestinal cancer operations, as well as factors associated with FT, remain unclear. METHODS We conducted a cross-sectional study by sending the Comprehensive Score for financial Toxicity (COST) survey and Surgery-Q (a survey specifically developed for this study) to patients who underwent gastrectomy or pancreatectomy for malignant disease at our institution in 2019-2021. RESULTS We sent the surveys to 627 patients and received responses from 101 (16%) patients. The FT prevalence (COST score <26) was 48 (48%). Patients likely to experience FT were younger than 50 years of age, of non-White race, earned an annual income <$75,000, and had credit scores <740 (all p < 0.05). Additionally, longer hospital stay (p = 0.041), extended time off work for surgery (p = 0.011), and extended time off work for caregivers (p = 0.005) were associated with FT. Procedure type was not associated with FT; however, patients who underwent minimally invasive surgery (MIS) had a lower FT probability (p = 0.042). In a multivariable analysis, age <50 years (p = 0.031) and credit score <740 (p < 0.001) were associated with high FT risk, while MIS was associated with low FT risk (p = 0.024). CONCLUSIONS Patients with upper gastrointestinal cancer have a major risk of FT. In addition to predicting the FT risk before surgery, facilitating quicker functional recovery with the appropriate use of MIS is considered important to reducing the FT risk.
Collapse
Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Connie To
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lyu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joyce P Samuel
- Division of Pediatric Nephrology and Hypertension, The University of Texas Health Science Center-Houston, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
5
|
Kobritz M, Nofi CP, Egunsola A, Zimmern AS. Financial toxicity in early-onset colorectal cancer: A National Health Interview Survey study. Surgery 2024; 175:1278-1284. [PMID: 38378347 DOI: 10.1016/j.surg.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Financial toxicity is increasingly recognized as a devastating outcome of cancer treatment but is poorly characterized in patients with early-onset colorectal cancer. Young patients are particularly vulnerable to financial toxicity as they are frequently underinsured and may suffer significant disruptions to professional and financial growth. We hypothesized that financial toxicity associated with colorectal cancer treatment confers long-lasting effects on patients' well-being and disproportionately impacts patients diagnosed at <50 years of age. METHODS A retrospective cross-sectional analysis of the National Health Interview Survey from years 2019 to 2021 was performed. Patients with a history of colorectal cancer were included and stratified by age at diagnosis. Randomly selected age-matched controls with no cancer history were used for comparison. The primary endpoint was financial toxicity, as assessed by a composite score formulated from 12 National Health Interview Survey items. The secondary endpoint was food security assessed by the United States Department of Agriculture's food security scale, embedded in the National Health Interview Survey. RESULTS When compared to age-matched controls, patients with colorectal cancer experienced significant financial toxicity, as reflected by a composite financial toxicity score (P = .027). Within patients with colorectal cancer, female sex (adjusted odds ratio = 1.46, P = .046) and early-onset disease (adjusted odds ratio = 2.11, P = .002) were found to significantly increase the risk of financial toxicity. Patients with early-onset colorectal cancer more frequently experienced food insecurity (P = .011), delayed necessary medical care (P = .053), mental health counseling (P = .043), and filling prescriptions (P = .007) due to cost when compared to patients with average-onset colorectal cancer. CONCLUSION Colorectal cancer is associated with significant long-term financial toxicity, which disproportionately impacts patients diagnosed at <50 years of age. Targeted interventions are warranted to reduce financial toxicity for patients with high-risk colorectal cancer.
Collapse
Affiliation(s)
- Molly Kobritz
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Surgery, Northwell-North Shore/Long Island Jewish, Manhasset, NY.
| | - Colleen P Nofi
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Surgery, Northwell-North Shore/Long Island Jewish, Manhasset, NY
| | - Adekemi Egunsola
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Surgery, Northwell-North Shore/Long Island Jewish, Manhasset, NY
| | - Andrea S Zimmern
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Surgery, Northwell-North Shore/Long Island Jewish, Manhasset, NY
| |
Collapse
|
6
|
Ciftci Y, Radomski SN, Johnston FM, Greer JB. ASO Author Reflections: Financial Toxicity and CRS-HIPEC-Is a Pound of Debt Worth an Ounce of Cure? Ann Surg Oncol 2024; 31:2401-2402. [PMID: 38087135 DOI: 10.1245/s10434-023-14768-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/25/2023] [Indexed: 03/06/2024]
Affiliation(s)
- Yusuf Ciftci
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
7
|
Lee Y, Anvari S, Padoan A, McKechnie T, Park L, Doumouras AG, Eskicioglu C, Hong D. Financial toxicity among patients undergoing resectional surgery for inflammatory bowel disease in the United States. Colorectal Dis 2024; 26:692-701. [PMID: 38353528 DOI: 10.1111/codi.16903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/11/2023] [Accepted: 01/21/2024] [Indexed: 05/02/2024]
Abstract
AIM Financial toxicity describes the financial burden and distress that patients experience due to medical treatment. Financial toxicity has yet to be characterized among patients with inflammatory bowel disease (IBD) undergoing surgical management of their disease. This study investigated the risk of financial toxicity associated with undergoing surgery for IBD. METHODS This study used a retrospective analysis using the National Inpatient Sample from 2015 to 2019. Adult patients who underwent IBD-related surgery were identified using the International Classification of Diseases (10th Revision) diagnostic and procedure codes and stratified into privately insured and uninsured groups. The primary outcome was risk of financial toxicity, defined as hospital admission charges that constituted 40% or more of patient's post-subsistence income. Secondary outcomes included total hospital admission cost and predictors of financial toxicity. RESULTS The analytical cohort consisted of 6412 privately insured and 3694 uninsured patients. Overall median hospital charges were $21 628 (interquartile range $14 758-$35 386). Risk of financial toxicity was 86.5% among uninsured patients and 0% among insured patients. Predictors of financial toxicity included emergency admission, being in the lowest residential income quartile and having ulcerative colitis (compared to Crohn's disease). Additional predictors were being of Black race or male sex. CONCLUSION Financial toxicity is a serious consequence of IBD-related surgery among uninsured patients. Given the pervasive nature of this consequence, future steps to support uninsured patients receiving surgery, in particular emergency surgery, related to their IBD are needed to protect this group from financial risk.
Collapse
Affiliation(s)
- Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Sama Anvari
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adelia Padoan
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lily Park
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
8
|
Ciftci Y, Radomski SN, Johnston FM, Greer JB. Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). Ann Surg Oncol 2024; 31:1980-1989. [PMID: 38044348 DOI: 10.1245/s10434-023-14577-y] [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: 08/21/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC. PATIENTS AND METHODS We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity. RESULTS Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile. CONCLUSIONS An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.
Collapse
Affiliation(s)
- Yusuf Ciftci
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
9
|
Romo Valenzuela A, Chervu NL, Roca Y, Sanaiha Y, Mallick S, Benharash P. Socioeconomic disparities in risk of financial toxicity following elective cardiac operations in the United States. PLoS One 2024; 19:e0292210. [PMID: 38295038 PMCID: PMC10830059 DOI: 10.1371/journal.pone.0292210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/13/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND While insurance reimbursements allay a portion of costs associated with cardiac operations, uncovered and additional fees are absorbed by patients. An examination of financial toxicity (FT), defined as the burden of patient medical expenses on quality of life, is warranted. Therefore, the present study used a nationally representative database to demonstrate the association between insurance status and risk of financial toxicity (FT) among patients undergoing major cardiac operations. METHODS Adults admitted for elective coronary artery bypass grafting (CABG) and isolated or concomitant valve operations were assessed using the 2016-2019 National Inpatient Sample. FT risk was defined as out-of-pocket expenditure >40% of post-subsistence income. Regression models were developed to determine factors associated with FT risk in insured and uninsured populations. To demonstrate the association between insurance status and risk of FT among patients undergoing major cardiac operations. RESULTS Of an estimated 567,865 patients, 15.6% were at risk of FT. A greater proportion of uninsured patients were at risk of FT (81.3 vs. 14.8%, p<0.001), compared to insured. After adjustment, FT risk among insured patients was not affected by non-income factors. However, Hispanic race (Adjusted Odds Ratio [AOR] 1.60), length of stay (AOR 1.17/day), and combined CABG-valve operations (AOR 2.31, all p<0.05) were associated with increased risk of FT in the uninsured. CONCLUSION Uninsured patients demonstrated higher FT risk after undergoing major cardiac operation. Hispanic race, longer lengths of stay, and combined CABG-valve operations were independently associated with increased risk of FT amongst the uninsured. Conversely, non-income factors did not impact FT risk in the insured cohort. Culturally-informed reimbursement strategies are necessary to reduce disparities in already financially disadvantaged populations.
Collapse
Affiliation(s)
- Alberto Romo Valenzuela
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Nikhil L. Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Yvonne Roca
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| |
Collapse
|
10
|
Lee Y, Kazi T, Dang J, Kroh M, Doumouras AG, Hong D. Financial toxicity risk among patients with gastric banding complications in the United States: analysis of the National Inpatient Sample. Surg Obes Relat Dis 2023; 19:1405-1414. [PMID: 37550162 DOI: 10.1016/j.soard.2023.07.002] [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: 02/27/2023] [Revised: 05/25/2023] [Accepted: 07/04/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Laparoscopic adjustable gastric banding (AGB) was historically among the most performed bariatric procedures but has fallen out of favor in recent years due to poor long-term weight loss and high revisional surgery rates. Significant financial hardship of medical care, known as "financial toxicity," can occur from experiencing unexpected complications of AGB. OBJECTIVE To investigate the risk of financial toxicity among patients being admitted for AGB complications. SETTING United States. METHODS All uninsured and privately-insured patients who were admitted for AGB complications were identified from the National Inpatient Sample 2015-2019. Publicly available government data (U.S. Census Bureau, Bureau of Labor, The Centers for Medicare and Medicaid Services) were utilized to estimate patient income, food expenditures, and average maximum out-of-pocket expenditures. Financial toxicity was defined as total admission cost from AGB complications ≥40% of postsubsistence income. RESULTS Among 28,005 patients, 66% patients had private insurance and 44% patients were uninsured. Median total admission cost was $12,443 (interquartile range $7959-$19,859) and $15,182 for those who received revisional bariatric surgery. Approximately 55% of the uninsured patients and 1% of insured patients were at risk of financial toxicity after admission for banding-related complications. Patients who had an emergency admission, revisional surgery, or postoperative intensive care unit admission were more likely to experience financial catastrophe following admission (P < .01). CONCLUSIONS About 1 in 2 uninsured patients admitted for AGB-related complications were at risk of financial toxicity. In addition to surgical risks, providers should consider the potential financial consequences of AGB when counselling patients on their choice of surgery.
Collapse
Affiliation(s)
- Yung Lee
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada; Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Tania Kazi
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jerry Dang
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matthew Kroh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Dennis Hong
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
11
|
Doherty M, Thom B, Gardner DS. Administrative Burden Associated with Cost-Related Delays in Care in U.S. Cancer Patients. Cancer Epidemiol Biomarkers Prev 2023; 32:1583-1590. [PMID: 37644659 DOI: 10.1158/1055-9965.epi-23-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/12/2023] [Accepted: 07/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND U.S. cancer patients engage in administrative tasks to pay for their healthcare. This study investigated the relationship between payment tasks and timely access to cancer care. METHODS We analyzed online survey data from 510 U.S. cancer patients and survivors to understand the relationship between administrative payment tasks and cost-related delays and nonadherence. Two-part modelling was used to determine if, and to what extent, there was a relationship between administrative burden and cost-related delays/nonadherence. RESULTS Younger patients (≤44 years) reported more payment tasks and cost-related delays/nonadherence than older patients (≥ 55 years); African American patients reported more payment tasks and cost-related delays/nonadherence than white patients. After accounting for age, race/ethnicity, education, and out-of-pocket costs, patients who reported engaging in more tasks had greater log odds of delaying/forgoing care [b = 0.18; 95% confidence interval (CI), 0.12-0.24]. Cost-related delays/nonadherence increased by 32% for every unit increase in administrative payment burden (b = 0.32; 95% CI, 0.18-0.46). CONCLUSIONS Administrative payment burden increased the odds of cost-related delays and nonadherence by 49%, taking the form of delayed or skipped doctor appointments, tests and bloodwork, and prescription fulfillment. Younger patients and those identifying as African American were more likely to engage in payment tasks and to delay or forgo care due to cost. Administrative burdens can disrupt access to care and traditionally underserved patient populations are disproportionately exposed to these hardships. IMPACT Reducing the complexity of healthcare through universal, human-centered design could reduce burdens and increase access.
Collapse
Affiliation(s)
- Meredith Doherty
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bridgette Thom
- Memorial Sloan Kettering Cancer Center Affordability Working Group, New York, New York
| | - Daniel S Gardner
- Silberman School of Social Work, Hunter College, City University of New York, New York
| |
Collapse
|
12
|
Lima HA, Moazzam Z, Woldesenbet S, Alaimo L, Endo Y, Munir MM, Shaikh CF, Resende V, Pawlik TM. Persistence of Poverty and its Impact on Surgical Care and Postoperative Outcomes. Ann Surg 2023; 278:347-356. [PMID: 37317875 DOI: 10.1097/sla.0000000000005953] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE We sought to characterize the association between prolonged county-level poverty with postoperative outcomes. BACKGROUND The impact of long-standing poverty on surgical outcomes remains ill-defined. METHODS Patients who underwent lung resection, colectomy, coronary artery bypass graft, or lower extremity joint replacement were identified from Medicare Standard Analytical Files Database (2015-2017) and merged with data from the American Community Survey and the United States Department of Agriculture. Patients were categorized according to the duration of high poverty status from 1980 to 2015 [ie, never high poverty (NHP), persistent poverty (PP)]. Logistic regression was used to characterize the association between the duration of poverty and postoperative outcomes. Principal component and generalized structural equation modeling were used to assess the effect of mediators in the achievement of Textbook Outcomes (TO). RESULTS Overall, 335,595 patients underwent lung resection (10.1%), colectomy (29.4%), coronary artery bypass graft (36.4%), or lower extremity joint replacement (24.2%). While 80.3% of patients lived in NHP, 4.4% resided in PP counties. Compared with NHP, patients residing in PP were at increased risk of serious postoperative complications [odds ratio (OR)=1.10, 95% CI: 1.05-1.15], 30-day readmission (OR=1.09, 95% CI: 1.01-1.16), 30-day mortality (OR=1.08, 95% CI: 1.00-1.17), and higher expenditures (mean difference, $1010.0, 95% CI: 643.7-1376.4) (all P <0.05). Notably, PP was associated with lower odds of achieving TO (OR=0.93, 95% CI: 0.90-0.97, P <0.001); 65% of this effect was mediated by other social determinant factors. Minority patients were less likely to achieve TO (OR=0.81, 95% CI: 0.79-0.84, P <0.001), and the disparity persisted across all poverty categories. CONCLUSIONS County-level poverty duration was associated with adverse postoperative outcomes and higher expenditures. These effects were mediated by various socioeconomic factors and were most pronounced among minority patients.
Collapse
Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad M Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Vivian Resende
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| |
Collapse
|
13
|
Nishtala MV, Reed M, Schumacher J, Hanlon B, Venkatesh M, Collins M, Zarzaur BL. Catastrophic health expenditure in nonneurological injury due to motor vehicle crash. J Trauma Acute Care Surg 2023; 95:172-180. [PMID: 37125834 PMCID: PMC10524788 DOI: 10.1097/ta.0000000000003993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Motor vehicle crashes (MVCs) are a leading cause of nonfatal injury in the United States and impose a high financial cost to the patient and the economy. For many patients, this cost may be financially devastating and contribute to worsening health outcomes after injury. We aimed to describe the population level risk of catastrophic health expenditure (CHE) and determine factors associated with risk of CHE. METHODS We performed a retrospective review using the 2014-2017 Nationwide Inpatient Sample. The study population consisted of uninsured and privately insured adults aged 26 to 64 years who were hospitalized for nonneurologic traumatic injury due to MVCs. Our measure of financial hardship was CHE, which was defined as hospital charges ≥40% of postsubsistence income. Income estimates were derived from zip-code level data using Γ distribution modeling. RESULTS Our sample included 189,000 patients, of which 149,705 had private insurance and 39,375 were uninsured. The median estimated income for the study cohort was $66,118 (interquartile range, $65,353-$66,884). The median cost of hospitalization was $53,467 (interquartile range, $29,854-$99,914). In addition, 91.5% of uninsured patients suffering from MVC are at risk for CHE, and 10.1% of privately insured patients are at risk for CHE. Among the insured, Black, Hispanic, and low income were associated with CHE. CONCLUSION Nine of 10 uninsured patients are at risk for CHE after hospitalization for MVC. Despite having insurance, 10% of patients are still at risk of CHE. Black, Hispanic, and low-income communities are at highest risk of having private insurance and still experiencing CHE. This is the first population level analysis after the implementation of the Affordable Care Act that assesses the financial burden of no insurance and underinsurance. These data are important to understand the effectiveness of insurance coverage and guide hospital and policy level interventions to prevent CHE. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
Collapse
Affiliation(s)
- Madhuri V Nishtala
- From the Department of Surgery (M.V.N., J.S., M.V., B.L.Z.), University of Wisconsin School of Medicine and Public Health; Department of Consumer Behavior and Family Economics (M.R.), University of Wisconsin-Madison; Department of Biostatistics and Medical Informatics (B.H.), University of Wisconsin School of Medicine and Public Health; and Department of Surgery (M.C.), Robert M. La Follette School of Public Affairs, University of Wisconsin-Madison, Madison, Wisconsin
| | | | | | | | | | | | | |
Collapse
|
14
|
Chervu N, Branche C, Verma A, Vadlakonda A, Bakhtiyar SS, Hadaya J, Benharash P. Association of insurance status with financial toxicity and outcome disparities after penetrating trauma and assault. Surgery 2023; 173:1493-1498. [PMID: 37031053 DOI: 10.1016/j.surg.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Financial toxicity, or the impact out-of-pocket medical expenses have on the quality of life, has not been widely enumerated in the trauma literature. We characterized the relationship between insurance status and the risk of financial toxicity after trauma and associated risk factors. METHODS Adults admitted for gunshot wounds, other penetrating injuries, or blunt assault were identified from the 2015 to 2019 National Inpatient Sample. The outcome of interest was a risk of financial toxicity with separate regression models for uninsured and insured populations. RESULTS Of an estimated 775,665 patients, 21.2% were at risk of financial toxicity. Patients at risk of financial toxicity were younger, more commonly male, less commonly White, and had a lower Elixhauser Index (Table 1). A higher proportion of uninsured patients were at risk of financial toxicity (40.8% vs 17.7%, P < .001) than insured patients. Whereas the proportion of uninsured patients at risk of financial toxicity significantly increased from 2015 to 2019, it was unchanged in insured patients. After adjustment, non-income demographic and clinical factors were not associated with the risk of financial toxicity amongst the insured. Conversely, the Black or Hispanic race, gunshot wounds, and any in-hospital complications were some factors associated with increased risk of financial toxicity in uninsured patients. CONCLUSION An increasingly larger proportion of uninsured patients are at risk of financial toxicity after trauma. The risk of financial toxicity among the uninsured was more complex than in the insured and associated with race, gunshot wounds, and complications. Increasing insurance access and the adoption of trauma-informed care practices should be used to address financial toxicity in this population.
Collapse
Affiliation(s)
- Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA. https://twitter.com/arjun_ver
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO. https://twitter.com/Aortologist
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA. https://twitter.com/CoreLabUCLA
| |
Collapse
|
15
|
Factors Potential Patients Deem Important for Decision-Making in High-Risk Surgical Scenarios. J Am Coll Surg 2023; 236:93-98. [PMID: 36519912 DOI: 10.1097/xcs.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Surgical futility and shared decision-making to proceed with high-risk surgery are challenging for patients and surgeons alike. It is unknown which factors contribute to a patient's decision to undergo high-risk and potentially futile surgery. The clinical perspective, founded in statistical probabilities of survival, could be misaligned with a patient's determination of worthwhile surgery. This study assesses factors most important to patients in pursuing high-risk surgery. STUDY DESIGN Via anonymous survey, lay participants recruited through Amazon's Mturk were presented high-risk scenarios necessitating emergency surgery. They rated factors (objective risk and quality-of-life domains) in surgical decision-making (0 = not at all, 4 = extremely) and made the decision to pursue surgery based on clinical scenarios. Repeated observations were accounted for via a generalized mixed-effects model and estimated effects of respondent characteristics, scenario factors, and likelihood to recommend surgery. RESULTS Two hundred thirty-six participants completed the survey. Chance of survival to justify surgery averaged 69.3% (SD = 21.3), ranking as the highest determining factor in electing for surgery. Other factors were also considered important in electing for surgery, including the average number of days the patient lived if surgery were and were not completed, functional and pain status after surgery, family member approval, and surgery cost. Postoperative independence was associated with proceeding with surgery (p < 0.001). Recommendations by patient age was moderated by respondent age (p = 0.002). CONCLUSION Patients highly value likelihood of survival and postoperative independence in shared decision-making for high-risk surgery. It is important to improve the understanding of surgical futility from a patient's perspective.
Collapse
|
16
|
Zhang Y, Cerullo M, Esposito A, Golla V. Association Between Cancer Center Accreditation and Compliance With Price Disclosure of Common Oncologic Surgical Procedures. J Natl Compr Canc Netw 2022; 20:1215-1222.e1. [PMID: 36351331 DOI: 10.6004/jnccn.2022.7057] [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: 04/07/2022] [Accepted: 07/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cancer center accreditation status is predicated on several factors that measure high-value healthcare. However, price transparency, which is critical in healthcare decisions, is not a quality measure included for accreditation. We reported the rates of price disclosure of surgical procedures for 5 cancers (breast, lung, cutaneous melanoma, colon, and prostate) among hospitals ranked by the American College of Surgeon's Commission on Cancer (ACS-CoC). METHODS We identified nonfederal, adult, and noncritical access ACS-CoC accredited hospitals and used the commercial Turquoise Health database to perform a cross-sectional analysis of hospital price disclosures for 5 common oncologic procedures (mastectomy, lobectomy, wide local excision for cutaneous melanoma, partial colectomy, prostatectomy). Publicly available financial reporting data were used to compile facility-specific features, including bed size, teaching status, Centers for Medicare & Medicaid wage index, and patient revenues. Modified Poisson regression evaluated the association between price disclosure and ACS-CoC accreditation after adjusting for hospital financial performance. RESULTS Of 1,075 total ACS-CoC accredited hospitals, 544 (50.6%) did not disclose prices for any of the surgical procedures and only 313 (29.1%) hospitals reported prices for all 5 procedures. Of the 5 oncologic procedures, prostatectomy and lobectomy had the lowest price disclosure rates. Disclosing and nondisclosing hospitals significantly differed in ACS-CoC accreditation, ownership type, and teaching status. Hospitals that disclosed prices were more likely to receive Medicaid disproportionate share hospital payments, have lower average charge to cost ratios (4.53 vs 5.15; P<.001), and have lower net hospital margins (-2.03 vs 0.44; P=.005). After adjustment, a 1-point increase in markup was associated with a 4.8% (95% CI, 2.2%-7.4%; P<.001) higher likelihood of nondisclosure. CONCLUSIONS More than half of the hospitals did not disclose prices for any of the 5 most common oncologic procedures despite ACS-CoC accreditation. It remains difficult to obtain price transparency for common oncologic procedures even at centers of excellence, signaling a discordance between quality measures visible to patients.
Collapse
Affiliation(s)
- Yuqi Zhang
- 1National Clinician Scholars Program, Duke University, Durham, North Carolina
- 2Department of Surgery, Yale University, New Haven, Connecticut
- 3Durham Veterans Affairs, Durham, North Carolina
| | - Marcelo Cerullo
- 1National Clinician Scholars Program, Duke University, Durham, North Carolina
- 3Durham Veterans Affairs, Durham, North Carolina
- 4Department of Surgery, Duke University, Durham, North Carolina
| | - Andrew Esposito
- 2Department of Surgery, Yale University, New Haven, Connecticut
| | - Vishnukamal Golla
- 1National Clinician Scholars Program, Duke University, Durham, North Carolina
- 3Durham Veterans Affairs, Durham, North Carolina
- 5Department of Surgery, Division of Urology, and
- 6Margolis Center for Health Policy, Duke University, Durham, North Carolina
| |
Collapse
|
17
|
Gao YN, Olfson M. Insurance and inpatient admission of emergency department patients with depression in the United States. Gen Hosp Psychiatry 2022; 78:28-34. [PMID: 35841753 PMCID: PMC9474607 DOI: 10.1016/j.genhosppsych.2022.07.003] [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: 06/15/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To estimate the contribution of insurance on rates of inpatient admission for emergency department visits with depression diagnoses. METHODS We identified 3,681,581 visits for depression in the National Emergency Department Sample (2007-2018). We classified them by concurrent injury, suicidal ideation, or neither. Payer categories were defined, non-exclusively, as Medicare, Medicaid, private insurance, and no insurance. Logistic regression models, adjusted for age, year, and comorbidities, were used to describe differences in rates of inpatient admission by payer type, stratified by visit features. RESULTS Rates of inpatient admission for visits with neither injury nor suicidal ideation (31.9%; 95%CI, 30.8-33.0) were lower than for visits with injury (37.9%; 95%CI, 36.7-39.1) or with suicidal ideation (39.7%; 95%CI, 37.3-42.1). Rates of admission were significantly lower for those without insurance (26.6%; 95%CI, 25.5-27.8) than for those with insurance (37.1%; 95%CI, 36.1-38.1). In adjusted models, insurance was associated with increased likelihood (OR = 1.81, 95%CI, 1.69-1.94) of admission. Insurance continued to be a significant predictor of admission among ED visits for depression with concurrent injury (OR = 1.39; 95%CI, 1.29-1.51). CONCLUSION After controlling for demographic characteristics and medical comorbidities, patients with depression who have insurance are significantly more likely to be admitted to the hospital compared to those without insurance.
Collapse
Affiliation(s)
- Y Nina Gao
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, USA.
| | - Mark Olfson
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, USA
| |
Collapse
|
18
|
Ng AP, Sanaiha Y, Verma A, Lee C, Akhavan A, Cohen JG, Benharash P. Insurance-based disparities and risk of financial toxicity among patients undergoing gynecologic cancer operations. Gynecol Oncol 2022; 166:200-206. [PMID: 35660294 DOI: 10.1016/j.ygyno.2022.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/18/2022] [Accepted: 05/22/2022] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the risk of financial toxicity (FT) among inpatients undergoing gynecologic cancer resections and the association of insurance status with clinical and financial outcomes. METHODS Using the 2008-2019 National Inpatient Sample, we identified adult hospitalizations for hysterectomy or oophorectomy with a diagnosis of cancer. Hospitalization costs, length of stay (LOS), mortality, and complications were assessed by insurance status. Risk of FT was defined as health expenditure exceeding 40% of post-subsistence income. Multivariable regressions were used to analyze costs and factors associated with FT risk. RESULTS Of 462,529 patients, 49.4% had government-funded insurance, 44.3% private, and 3.2% were uninsured. Compared to insured, uninsured patients were more commonly Black and Hispanic, admitted emergently, and underwent open operations. Uninsured patients experienced similar mortality but greater rates of complications, LOS, and costs. Overall, ovarian cancer resections had the highest median costs of $17,258 (interquartile range: 12,187-25,491) compared to cervical and uterine. Approximately 52.8% of uninsured and 15.4% of insured patients were at risk of FT. As costs increased across both cohorts over the 12-year study period, the disparity in FT risk by payer status broadened. After risk adjustment, perioperative complications were associated with nearly 2-fold increased risk of FT among uninsured (adjusted odds ratio 1.75, 95% confidence interval 1.46-2.09, p < 0.001). Among the insured, Black and Hispanic race, public insurance, and open operative approach exhibited greater odds of FT. CONCLUSION Patients undergoing gynecologic cancer operations are at substantial risk of FT, particularly those uninsured. Targeted cost-mitigation strategies are warranted to minimize financial burden.
Collapse
Affiliation(s)
- Ayesha P Ng
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Cory Lee
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Aaron Akhavan
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Joshua G Cohen
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
| |
Collapse
|
19
|
Sarap MD. Quality and Value in Rural Cancer Care. Am Surg 2022; 88:1749-1753. [PMID: 35430908 DOI: 10.1177/00031348221086801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nearly 60 million people reside in rural America with only 10% of US general surgeons providing for their surgical care. Rural cancer care has been maligned in the literature due to a lack of understanding of local resource limitations and to the difficulties involved in documenting the quality of local cancer care in small and rural communities. A majority of US cancer patients are diagnosed and treated in community cancer programs, many of which are Commission on Cancer Accredited and deliver care that is of high quality and value. The article discusses the components of high quality health care and offers suggestions for solo or small group rural surgeons to assist in collection of their own quality data and comparison to national benchmarks. One small rural program in Appalachian Ohio is used for a best-case example.
Collapse
Affiliation(s)
- Michael D Sarap
- 21457Southeastern Ohio Regional Medical Center, Cambridge, OH, USA
| |
Collapse
|
20
|
Critical Competences for the Management of Post-Operative Course in Patients with Digestive Tract Cancer: The Contribution of MADIT Methodology for a Nine-Month Longitudinal Study. Behav Sci (Basel) 2022; 12:bs12040101. [PMID: 35447673 PMCID: PMC9029589 DOI: 10.3390/bs12040101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/25/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
There is a high postoperative morbidity rate after cancer surgery, that impairs patients’ self-management, job condition and economic strength. This paper describes the results of a peculiar psychological intervention on patients undergoing surgery for esophageal, gastric and colorectal cancer. The intervention aimed to enhance patients’ competences in the management of postoperative daily life. A narrative approach (M.A.D.I.T.—Methodology for the Analysis of Computerised Text Data) was used to create a questionnaire, Health and Employment after Gastro-Intestinal Surgery—Dialogical Questionnaire, HEAGIS-DQ, that assesses four competences. It was administered to 48 participants. Results were used as guidance for specific intervention, structured on patients’ competence profiles. The intervention lasted nine months after surgery and was structured in weekly to monthly therapeutic sessions. Quality of Life questionnaires were administered too. At the end of the intervention, 94% of patients maintained their job and only 10% of patients asked for financial support. The mean self-perception of health-related quality of life was 71.2. The distribution of three of four competences increased after nine months (p < 0.05). Despite economic difficulties due to lasting symptoms after surgery, and to the current pandemic scenario, a structured intervention with patients let them to resume their jobs and continue activities after surgery.
Collapse
|
21
|
Yu H, Li H, Zuo T, Cao L, Bi X, Xing H, Cai L, Sun J, Liu Y. Financial Toxicity and psychological distress in Adults with Cancer: A Treatment-based Analysis. Asia Pac J Oncol Nurs 2022; 9:100069. [PMID: 35669288 PMCID: PMC9166374 DOI: 10.1016/j.apjon.2022.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To evaluate disparities in financial toxicity and psychological distress in patients with cancer as a function of treatment and reveal the relationship between financial toxicity and psychological distress. Methods This was a multicenter cross-sectional study. Patients were recruited from March 2017 to October 2018, and questionnaires were completed regarding their demographics, financial toxicity, and psychological distress. A multiple linear regression model was used to examine factors associated with financial and psychological distress. Results Significant financial toxicity and psychological distress occurred in 47.9% and 56.5% of patients, respectively. Financial toxicity (P = 0.032) and psychological distress (P < 0.001) were statistically different among the single chemotherapy, adjuvant therapy, and surgery groups. Multivariable analysis revealed that patients aged 50–59 years (P = 0.035), 60–69 years (P = 0.007), and 70 years or older (P = 0.002) had higher the Comprehensive Score for financial Toxicity (COST) scores compared with patients less than 50 years old. Patients with personal annual income > 40,000 CNY reported higher COST scores than those who had < 20,000 CNY (P < 0.001). Patients who had Urban Resident Basic Medical Insurance (URBMI) (P = 0.030) or New Rural Cooperative Medical Scheme (NRCMS) (P = 0.006) compared with Urban Employee Basic Medical Insurance (UEBMI) presented lower COST scores than patients with UEBMI. The multiple analysis model of psychological distress showed that an age of more than 70 years (P = 0.010) was significantly associated with low the Distress Thermometer (DT) scores, and patients with colorectal cancer (P = 0.009), the surgery group (P < 0.001) and adjuvant therapy group (P < 0.001) were significantly associated with high DT scores. The correlations between financial toxicity and psychological distress were mild but statistically significant in the chemotherapy-related treatment groups. Conclusions The research highlights the high rates of financial and psychological distress in adult patients. Multidimensional distress screening and psychosocial interventions should be provided for patients with cancer according to related factors.
Collapse
|
22
|
Albright BB, Nitecki R, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States. Am J Obstet Gynecol 2022; 226:384.e1-384.e13. [PMID: 34597606 PMCID: PMC10016333 DOI: 10.1016/j.ajog.2021.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. STUDY DESIGN We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. RESULTS We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. CONCLUSION Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.
Collapse
Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emeline M Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| |
Collapse
|
23
|
|
24
|
Albright BB, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Associations of Insurance Churn and Catastrophic Health Expenditures With Implementation of the Affordable Care Act Among Nonelderly Patients With Cancer in the United States. JAMA Netw Open 2021; 4:e2124280. [PMID: 34495338 PMCID: PMC8427370 DOI: 10.1001/jamanetworkopen.2021.24280] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Health insurance coverage is dynamic in the United States, potentially changing from month to month. The Patient Protection and Affordable Care Act (ACA) aimed to stabilize markets and reduce financial burden, particularly among those with preexisting conditions. OBJECTIVE To describe the risks of insurance churn (ie, gain, loss, or change in coverage) and catastrophic health expenditures among nonelderly patients with cancer in the United States, assessing for changes associated with ACA implementation. DESIGN, SETTING, AND PARTICIPANTS This retrospective, cross-sectional study uses data from the Medical Expenditure Panel Survey, a representative sample of the US population from 2005 to 2018. Respondents included were younger than 65 years, identified by health care use associated with a cancer diagnosis code in the given year. Statistical analysis was conducted from July 30, 2020, to January 5, 2021. EXPOSURES The Patient Protection and Affordable Care Act. MAIN OUTCOMES AND MEASURES Survey weights were applied to generate estimates for the US population. Annual risks of insurance churn (ie, any uninsurance or insurance change or loss) and catastrophic health expenditures (spending >10% income) were calculated, comparing subgroups with the adjusted Wald test. Weighted multivariable linear regression was used to assess for changes associated with ACA implementation. RESULTS From 6069 respondents, we estimated a weighted mean of 4.78 million nonelderly patients (95% CI, 4.55-5.01 million; female patients: weighted mean, 63.9% [95% CI, 62.2%-65.7%]; mean age, 50.3 years [95% CI, 49.7-50.8 years]) with cancer annually in the United States. Patients with cancer experienced lower annual risks of insurance loss (5.3% [95% CI, 4.5%-6.1%] vs 7.6% [95% CI, 7.4%-7.8%]) and any uninsurance (14.6% [95% CI, 13.3%-16.0%] vs 24.1% [95% CI, 23.5%-24.7%]) but increased risk of catastrophic health expenditures (expenses alone: 12.4% [95% CI, 11.2%-13.6%] vs 6.3% [95% CI, 6.2%-6.5%]; including premiums: 26.6% [95% CI, 25.0%-28.1%] vs 16.5% [95% CI, 16.1%-16.8%]; P < .001) relative to the population without cancer. Patients with cancer from low-income families and with full-year private coverage were at particularly high risk of catastrophic health expenditures (including premiums: 81.7% [95% CI, 74.6%-88.9%]). After adjustment, low income was the factor most strongly associated with both insurance churn and catastrophic spending, associated with annual risk increases of 6.5% (95% CI, 4.2%-8.8%) for insurance loss, 17.3% (95% CI, 13.4%-21.2%) for any uninsurance, and 37.4% (95% CI, 33.3%-41.6%) for catastrophic expenditures excluding premiums (P < .001). In adjusted models relative to 2005-2009, full ACA implementation (2014-2018) was associated with a decreased annual risk of any uninsurance (-4.2%; 95% CI, -7.4% to -1.0%; P = .01) and catastrophic spending by expenses alone (-3.0%; 95% CI, -5.3% to -0.8%; P = .008) but not including premiums (0.4%; 95% CI, -2.8% to 4.5%; P = .82). CONCLUSIONS AND RELEVANCE In this cross-sectional study, US patients with cancer faced significant annual risks of insurance churn and catastrophic health spending. Despite some improvements with ACA implementation, large burdens remained, and further reform is needed to protect this population from excessive hardship.
Collapse
Affiliation(s)
- Benjamin B. Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junzo P. Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Emeline M. Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Haley A. Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
25
|
Herb J, Williams B, Stitzenberg K. Hospital Price Transparency Rules are Inadequate to Inform Patients Needing Major Gastrointestinal Cancer Operations. Ann Surg Oncol 2021; 29:45-46. [PMID: 34095959 DOI: 10.1245/s10434-021-10244-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/20/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Joshua Herb
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Brittney Williams
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karyn Stitzenberg
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
26
|
The impact of social vulnerability subthemes on postoperative outcomes differs by racial/ethnic minority status. Am J Surg 2021; 223:353-359. [PMID: 34099239 DOI: 10.1016/j.amjsurg.2021.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Social vulnerability is an important driver of disparate surgical outcomes, however the extent to which certain types of vulnerability impact outcomes is poorly understood. METHODS Medicare beneficiaries 65 years or older who underwent one of four operations were identified. Multivariable mixed-effects logistic regression was used to measure the association of four social vulnerability subthemes from the social vulnerability index (SVI) were assessed relative to the likelihood to achieve a textbook outcome (TO). RESULTS Among 579,846 Medicare beneficiaries, median age was 74 years and most patients (536,455,92.5%) were White/non-Hispanic. On multivariable analysis, the overall impact of the composite SVI metric on the odds to achieve a postoperative TO was lower among White/non-Hispanic patients (Δ25%ile SVI:OR:0.98,95%CI:0.97-0.98) compared with ethnic/minority patients (Δ25%ile SVI:OR:0.93,95%CI:0.91-0.94). Increasing vulnerability in the subthemes of socioeconomic status (Δ25%ile SVI:ethnic/minority:OR:0.92, 95%CI:0.91-0.94) and household composition (Δ25%ile SVI:ethnic/minority:OR:0.92,95%CI:0.91-0.94) was associated with a greater likelihood not to achieve a TO among minority patients. CONCLUSIONS Worsening SES and household compositions & disability had a detrimental effect on odds of TO following surgery with the most pronounced effect on non-White minority patients.
Collapse
|
27
|
Sidey-Gibbons C, Pfob A, Asaad M, Boukovalas S, Lin YL, Selber JC, Butler CE, Offodile AC. Development of Machine Learning Algorithms for the Prediction of Financial Toxicity in Localized Breast Cancer Following Surgical Treatment. JCO Clin Cancer Inform 2021; 5:338-347. [PMID: 33764816 PMCID: PMC8140797 DOI: 10.1200/cci.20.00088] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/16/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Financial burden caused by cancer treatment is associated with material loss, distress, and poorer outcomes. Financial resources exist to support patients but identification of need is difficult. We sought to develop and test a tool to accurately predict an individual's risk of financial toxicity based on clinical, demographic, and patient-reported data prior to initiation of breast cancer treatment. PATIENTS AND METHODS We surveyed 611 patients undergoing breast cancer therapy at MD Anderson Cancer Center. We collected data using the validated COmprehensive Score for financial Toxicity (COST) patient-reported outcome measure alongside other financial indicators (credit score, income, and insurance status). We also collected clinical and perioperative data. We trained and tested an ensemble of machine learning (ML) algorithms (neural network, regularized linear model, support vector machines, and a classification tree) to predict financial toxicity. Data were randomly partitioned into training and test samples (2:1 ratio). Predictive performance was assessed using area-under-the-receiver-operating-characteristics-curve (AUROC), accuracy, sensitivity, and specificity. RESULTS In our test sample (N = 203), 48 of 203 women (23.6%) reported significant financial burden. The algorithm ensemble performed well to predict financial burden with an AUROC of 0.85, accuracy of 0.82, sensitivity of 0.85, and specificity of 0.81. Key clinical predictors of financial burden from the linear model were neoadjuvant therapy (βregularized, .11) and autologous, rather than implant-based, reconstruction (βregularized, .06). Notably, radiation and clinical tumor stage had no effect on financial burden. CONCLUSION ML models accurately predicted financial toxicity related to breast cancer treatment. These predictions may inform decision making and care planning to avoid financial distress during cancer treatment or enable targeted financial support. Further research is warranted to validate this tool and assess applicability for other types of cancer.
Collapse
Affiliation(s)
- Chris Sidey-Gibbons
- Department of Symptom Research, University of Texas MD Anderson Cancer Center, Houston, TX
| | - André Pfob
- Department of Obstetrics and Gynecology, Heidelberg University, Heidelberg, Germany
| | - Malke Asaad
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stefanos Boukovalas
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yu-Li Lin
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jesse Creed Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles E. Butler
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anaeze Chidiebele Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX
- Institute for Cancer Care Innovation, University of Texas MD Anderson Cancer Center, Houston, TX
- Baker Institute for Public Policy, Rice University, Houston, TX
| |
Collapse
|
28
|
Rice DR, Hyer JM, Diaz A, Pawlik TM. End-of-Life Hospice Use and Medicare Expenditures Among Patients Dying of Hepatocellular Carcinoma. Ann Surg Oncol 2021; 28:5414-5422. [PMID: 33528708 DOI: 10.1245/s10434-021-09606-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The increasing incidence of hepatocellular carcinoma (HCC) coupled with rising health care costs contributes to high end-of-life expenditures. The current study aimed to characterize health care expenditures and hospice use among patients with HCC using a large, national database. METHODS The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was used to identify patients with HCC. Logistic regression was used to identify factors associated with overall hospice use and end-of-life expenditures among individuals who died of HCC. RESULTS Among 14,369 Medicare beneficiaries with HCC, 8069 (63.7 %) used hospice. Racial/ethnic minority patients were less likely to use hospice services during the last year of life than white patients (no hospice: n = 2034 [44.3 %] vs. hospice: n = 2513 [31.1 %]). Social vulnerability also had an impact on the likelihood of patients using hospice services; in particular, the probability of hospice use among patients declined as social vulnerability increased (P < 0.05). Hospice use was associated with an approximate $10,000 decrease in inpatient expenditures (hospice: US$7900 [IQR, US$0-26,600] vs. no hospice: US$18,000 [IQR $400-49,100]; P < 0.001) and $1300 decrease in outpatient expenditures (hospice: US$900 [IQR, US$0-4500] vs. non-hospice: US$2200 [IQR, US$200-7900; P < 0.001) compared with individuals who did not use hospice. CONCLUSIONS Minority patients and individuals residing in high-vulnerability areas were less likely to use hospice. Patients who used hospice at the end of life had a reduction in inpatient and outpatient Medicare claims. Patients with HCC in need of hospice services should be ensured timely referral regardless of race/ethnicity or social vulnerability.
Collapse
Affiliation(s)
- Daniel R Rice
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
| |
Collapse
|
29
|
Hyer JM, Tsilimigras DI, Diaz A, Mirdad RS, Azap RA, Cloyd J, Dillhoff M, Ejaz A, Tsung A, Pawlik TM. High Social Vulnerability and "Textbook Outcomes" after Cancer Operation. J Am Coll Surg 2021; 232:351-359. [PMID: 33508426 DOI: 10.1016/j.jamcollsurg.2020.11.024] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer. METHODS Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression. RESULTS Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05). CONCLUSIONS Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.
Collapse
Affiliation(s)
- J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | | | - Rosevine A Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH.
| |
Collapse
|
30
|
County-Level Social Vulnerability is Associated with Worse Surgical Outcomes Especially Among Minority Patients. Ann Surg 2020; 274:881-891. [PMID: 33351455 DOI: 10.1097/sla.0000000000004691] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to characterize the association between patient county-level vulnerability with postoperative outcomes. SUMMARY BACKGROUND DATA While the impact of demographic-, clinical- and hospital-level factors on outcomes following surgery have been examined, little is known about the effect of a patient's community of residence on surgical outcomes. METHODS Individuals who underwent colon resection, coronary artery bypass graft (CABG), lung resection, or lower extremity joint replacement (LEJR) were identified in the 2016-2017 Medicare database, which was merged with CDC vulnerability index (SVI) dataset at the beneficiary level of residence. Logistic regression models were utilized to estimate the probability of postoperative complications, mortality, readmission, and expenditures. RESULTS Among 299,583 Medicare beneficiary beneficiaries who underwent a colectomy (n = 88,778, 29.6%), CABG (n = 109,564, 36.6%), lung resection (n = 30,401, 10.1%), or LEJR (n = 70,840, 23.6%).Mean SVI score was 50.2 (SD: (25.2); minority patients were more likely to reside in highly vulnerable communities (low SVI: n = 3,531, 5.8% vs. high SVI: n = 7,895, 13.3%; p < 0.001). After controlling for competing risk factors, the risk-adjusted probability of a serious complication among patients from a high versus low SVI county was 10-20% higher following colectomy (OR 1.1 95%CI 1.1-1.2) or CABG (OR 1.2 95%CI 1.1-1.3), yet there no association of SVI with risk of serious complications following lung resection (OR 1.2 95%CI 1.0-1.3) or LEJR (OR 1.0 95%CI 0.93-1.2). The risk-adjusted probability of 30-day mortality was incrementally higher among patients from high SVI counties following colectomy (OR 1.1 95%CI 1.1-1.3), CABG (OR 1.4, 95%CI 1.2-1.5), and lung resection (OR 1.4 (95%CI 1.1-1.8), yet not LEJR (OR 0.95 95%CI 0.72-1.2). Black/minority patients undergoing a colectomy, CABG, or lung resection who lived in highly socially vulnerable counties had an estimate 28-68% increased odds of a serious complication and a 58-60% increased odds of 30-day mortality compared with a black/minority patient from a low socially vulnerable county, as well as a markedly higher risk than white patients (all p > 0.05). CONCLUSION Patients residing in vulnerable communities characterized by a high SVI generally had worse postoperative outcomes. The impact of social vulnerability was most pronounced among black/minority patients, rather than white individuals. Efforts to ensure equitable surgical outcomes need to focus on both patient-level, as well as community-specific factors.
Collapse
|
31
|
Okoroh JS, Weaver L, Heslin MJ, Vickers SM, Wang TN, Rose JB, Reddy S. Does health insurance protect against risk of financial catastrophe for pancreatic tumor care? A cost-based review of patients undergoing pancreatic resection at an academic institution. Am J Surg 2020; 222:139-144. [PMID: 33279170 DOI: 10.1016/j.amjsurg.2020.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pancreatic cancer is a leading cause of financial insolvency and cancer related deaths in the United States. The risk of catastrophic health expenditure (CHE) was calculated for patients undergoing pancreatic resection at an academic institution. METHODS Patients who underwent pancreatic resection between 2013 and 2017 were identified through an institutional cancer registry. A CHE was an out-of-pocket payment (OOP) > 10% of the estimated median household income. RESULTS 319 patients met inclusion criteria. Hospital median charge was $76,700. 99% of patients had insurance and hospital bill adjustments. As a result, 61% (n = 193) made no OOP. Only 3 patients risked CHE. For all tumors combined there were no differences in survival outcomes by OOP. CONCLUSION This is the first study to use institutional financial data to calculate CHE risk for pancreatic resection patients. Insurance adjustments to hospital charges that accompany health insurance and voluntary hospital adjustments for the uninsured protect patients against CHE.
Collapse
Affiliation(s)
- Juliet S Okoroh
- Department of Surgery, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, USA
| | - Lauren Weaver
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, USA
| | - Martin J Heslin
- Department of Surgery, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, USA
| | - Selwyn M Vickers
- Department of Surgery, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, USA
| | - Thomas N Wang
- Department of Surgery, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, USA
| | - J Bart Rose
- Department of Surgery, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, USA
| | - Sushanth Reddy
- Department of Surgery, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, USA.
| |
Collapse
|
32
|
Abstract
The article describes the barriers rural surgeons face when attempting to measure, analyze, and benchmark the quality and value of the care they provide for their patients. Examples of suboptimal care are presented as well as special geographic and resource-related circumstances for many of these disparities of care. The article includes in-depth descriptions of the American College of Surgeons (ACS) Optimal Resources for Surgical Quality and Safety Program and the ACS Rural Hospital Surgical Verification and Quality Improvement Program. The article concludes by discussing several documented clinical, economic, and social advantages of keeping surgical care local.
Collapse
Affiliation(s)
- Michael Duke Sarap
- SE Med Department of Surgery, Cambridge, OH, USA; American College of Surgeons, Advisory Council for Rural Surgery; Commission on Cancer Program in Ohio; Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA; Lake Erie College of Medicine, Erie, PA, USA; Physicians Assistant Program, Marietta College; Tina Kiser Cancer Concern Coalition.
| |
Collapse
|
33
|
Siegel RL, Jakubowski CD, Fedewa SA, Davis A, Azad NS. Colorectal Cancer in the Young: Epidemiology, Prevention, Management. Am Soc Clin Oncol Educ Book 2020; 40:1-14. [PMID: 32315236 DOI: 10.1200/edbk_279901] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Colorectal cancer (CRC) incidence rates in the United States overall have declined since the mid-1980s because of changing patterns in risk factors (e.g., decreased smoking) and increases in screening. However, this progress is increasingly confined to older adults. CRC occurrence has been on the rise in patients younger than age 50, often referred to as early-onset disease, since the mid-1990s. Young patients are more often diagnosed at an advanced stage and with rectal disease than their older counterparts, and they have numerous other unique challenges across the cancer management continuum. For example, young patients are less likely than older patients to have a usual source of health care; often need a more complex treatment protocol to preserve fertility and sexual function; are at higher risk of long-term and late effects, including subsequent primary malignancies; and more often suffer medical financial hardship. Diagnosis is often delayed because of provider- and patient-related factors, and clinicians must have a high index of suspicion if young patients present with rectal bleeding or changes in bowel habits. Educating primary care providers and the larger population on the increasing incidence and characteristic symptoms is paramount. Morbidity can further be averted by increasing awareness of the criteria for early screening, which include a family history of CRC or polyps and a genetic predisposition.
Collapse
Affiliation(s)
| | | | | | | | - Nilofer S Azad
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| |
Collapse
|