Demographic Analysis of Financial Hardships Faced by Brain Tumor Survivors

Financial Toxicity in High-Grade Glioma Resection: A Retrospective Analysis

BACKGROUND

Despite its association with lower survival rates among patients in various disease states, financial toxicity is often overlooked in health care. The aims of our study are to elucidate the effect of financial toxicity on the care of glioma patients.

METHODS

We retrospectively evaluated clinical information of 130 patients with newly diagnosed glioblastoma from a single institution between 2014 and 2021. The Area Deprivation Index characterized patients' socioeconomic status. Insurance claims were analyzed to assess the financial burden on patients following their neurosurgical procedure. This burden was then compared with socioeconomic factors using adjusted multivariable regression models.

RESULTS

A total of 55 (42%) patients had out-of-pocket (OOP) costs with 24 (18%) unable to pay off their procedure. High socioeconomic disadvantage (3.01; P=0.02); other race (0.166; P=0.039); and public insurance (0.114; P<0.0001) were significantly associated with an increased risk of accumulating OOP costs. Age (0.097; P=0.026); African American race (29.87; P=0.029); marriage status (0.114; P=0.017); and high socioeconomic disadvantage (5.96; P=0.031) were significantly associated with risk of payments being sent to collections. Those with private insurance accrued higher gross OOP costs (1093 vs. 506, [P < 0.001]). Those with public insurance had a lower hazard of death (0.397; P=0.003).

CONCLUSIONS

Our results suggest there is a strong association between financial toxicity, socioeconomic status, and the standard of care following GBM resection. They also shed light on the financial toxicities associated with the care of these patients.

Identifying research priorities and essential elements of palliative care services for people facing malignant brain tumors: A participatory co-design approach

Background

Primary malignant brain tumors (ie, brain cancer) impact the quality of life (QoL) for patients and care partners in disease-specific ways involving cognition and communication. Palliative care (PC) addresses patient/care partner QoL, but it is not known how PC may address the unique needs of brain cancer patients. The purpose of this project was to identify brain cancer PC research priorities using participatory co-design methods.

Methods

Participatory co-design included the formation of a longitudinal, collaborative advisory group, engagement frameworks, design-thinking processes, and social media-based engagement over a 1-year period. Community-identified brain cancer QoL needs and research priorities were mapped to proposed "essential elements" of brain cancer PC services.

Results

We engaged an estimated 500 patients, care partners, healthcare professionals, and others with an interest in QoL and PC services for people with malignant brain tumors. Research priorities included testing the early introduction of PC services designed to address the unique QoL needs of brain cancer patients and care partners. Essential elements of brain cancer PC include: (1) addressing brain cancer patients' unique range of QoL needs and concerns, which change over time, (2) tailoring existing services and approaches to patient needs and concerns, (3) enhancing the involvement of interprofessional care team members, and (4) optimizing timing for PC services. This was the first participatory research effort exploring brain cancer patient and care partner QoL needs and PC services.

Conclusions

The brain tumor community calls for research testing PC service models for patients that incorporate the "essential elements" of palliative care.

Challenges and Opportunities in Accessing Surgery for Glioblastoma in Low-Middle Income Countries: A Narrative Review

Glioblastoma: a highly aggressive brain tumor, presents substantial challenges in treatment and management, with surgical intervention playing a pivotal role in improving patient outcomes. Disparities in access to brain tumor surgery arise from a multitude of factors, including socioeconomic status, geographical location, and healthcare resource allocation. Low- and middle-income countries (LMICs) often face significant barriers to accessing surgical services, such as shortages of specialized neurosurgical expertise, limited healthcare infrastructure, and financial constraints. Consequently, glioblastoma patients in LMICs experience delays in diagnosis, suboptimal treatment, and poorer clinical outcomes compared to patients in high-income countries (HICs). The clinical impact of these disparities is profound. Patients in LMICs are more likely to be diagnosed at advanced disease stages, receive less effective treatment, and have lower survival rates than their counterparts in HICs. Additionally, disparities in access to surgical care exacerbate economic and societal burdens, emphasizing the urgent need for targeted interventions and health policy reforms to address healthcare inequities. This review highlights the importance of addressing global disparities in access to brain tumor surgery for glioblastoma through collaborative efforts, policy advocacy, and resource allocation, aiming to improve outcomes and promote equity in surgical care delivery for all glioblastoma patients worldwide.

The relationship between social determinants of health and neurocognitive and mood-related symptoms in the primary brain tumor population: A systematic review

Social determinants of health (SDOH) impact cancer-related health outcomes, including survival, but their impact on symptoms is less understood among the primary brain tumor (PBT) population. We conducted a systematic review to examine the relationships between SDOH and neurocognitive and mood-related symptoms among the PBT population. PubMed, EMBASE, and CINAHL were searched using PROGRESS criteria (place of residence, race/ethnicity, occupation, gender/sex, religion, education, socioeconomic status, and social capital) on March 8th, 2022. Two individuals screened and assessed study quality using the NHLBI Assessment Tool for Observational Cohort and Cross-sectional Studies. Of 3006 abstracts identified, 150 full-text articles were assessed, and 48 were included for a total sample of 28 454 study participants. Twenty-two studies examined 1 SDOH; none examined all 8. Four studies measured place of residence, 2 race/ethnicity, 13 occupation, 42 gender, 1 religion, 18 education, 4 socioeconomic status, and 15 social capital. Fifteen studies assessed neurocognitive and 37 mood-related symptoms. While higher education was associated with less neurocognitive symptoms, and among individuals with meningioma sustained unemployment after surgery was associated with depressive symptoms, results were otherwise disparate among SDOH and symptoms. Most studies were descriptive or exploratory, lacking comprehensive inclusion of SDOH. Standardizing SDOH collection, reducing bias, and recruiting diverse samples are recommended in future interventions.

High costs, low quality of life, reduced survival, and room for improving treatment: an analysis of burden and unmet needs in glioma

Gliomas are a group of heterogeneous tumors that account for substantial morbidity, mortality, and costs to patients and healthcare systems globally. Survival varies considerably by grade, histology, biomarkers, and genetic alterations such as IDH mutations and MGMT promoter methylation, and treatment, but is poor for some grades and histologies, with many patients with glioblastoma surviving less than a year from diagnosis. The present review provides an introduction to glioma, including its classification, epidemiology, economic and humanistic burden, as well as treatment options. Another focus is on treatment recommendations for IDH-mutant astrocytoma, IDH-mutant oligodendroglioma, and glioblastoma, which were synthesized from recent guidelines. While recommendations are nuanced and reflect the complexity of the disease, maximum safe resection is typically the first step in treatment, followed by radiotherapy and/or chemotherapy using temozolomide or procarbazine, lomustine, and vincristine. Immunotherapies and targeted therapies currently have only a limited role due to disappointing clinical trial results, including in recurrent glioblastoma, for which the nitrosourea lomustine remains the de facto standard of care. The lack of treatment options is compounded by frequently suboptimal clinical practice, in which patients do not receive adequate therapy after resection, including delayed, shortened, or discontinued radiotherapy and chemotherapy courses due to treatment side effects. These unmet needs will require significant efforts to address, including a continued search for novel treatment options, increased awareness of clinical guidelines, improved toxicity management for chemotherapy, and the generation of additional and more robust clinical and health economic evidence.

Financial stress among skin cancer patients: a cross-sectional review of the 2013-2018 National Health Interview Survey

Financial stress among skin cancer patients may limit treatment efficacy by forcing the postponement of care or decreasing adherence to dermatologist recommendations. Limited information is available quantifying the anxiety experienced by skin cancer patients from both healthcare and non-healthcare factors. Therefore, the present study sought to perform a retrospective cross-sectional review of the 2013-2018 cycles of the National Health Interview Survey (NHIS) to determine the prevalence, at-risk groups, and predictive factors of skin cancer patient financial stress. Survey responses estimated that 11.45% (95% Cl 10.02-12.88%) of skin cancer patients experience problems paying medical bills, 20.34% (95% Cl 18.97-21.71%) of patients worry about the medical costs, 13.73% (95% Cl 12.55-14.91%) of patients worry about housing costs, and 37.48% (95% Cl 35.83-39.14%) of patients worry about money for retirement. Focusing on at-risk groups, black patients, uninsured patients, and patients with low incomes (< 200% poverty level) consistently experienced high rates of financial stress for each of the four measures. Multivariable logistic regression revealed low education, lack of insurance, and low income to be predictive of financial stress. These findings suggest that a considerable proportion of skin cancer patients experience financial stress related to both healthcare and non-healthcare factors. Where possible, the additional intricacy of treating patients at risk of high financial stress may be considered to optimize patient experience and outcomes.

Do Patients Reporting Fractures Experience Food Insecurity More Frequently Than the General Population?

BACKGROUND

The economic burden of traumatic injuries forces families into difficult tradeoffs between healthcare and nutrition, particularly among those with a low income. However, the epidemiology of food insecurity among individuals reporting having experienced fractures is not well understood.

QUESTIONS/PURPOSES

(1) Do individuals in the National Health Interview Survey reporting having experienced fractures also report food insecurity more frequently than individuals in the general population? (2) Are specific factors associated with a higher risk of food insecurity in patients with fractures?

METHODS

This retrospective, cross-sectional analysis of the National Health Interview Survey was conducted to identify patients who reported a fracture within 3 months before survey completion. The National Health Interview Survey is an annual serial, cross-sectional survey administered by the United States Centers for Disease Control, involving approximately 90,000 individuals across 35,000 American households. The survey is designed to be generalizable to the civilian, noninstitutionalized United States population and is therefore well suited to evaluate longitudinal trends in physical, economic, and psychosocial health factors nationwide. We analyzed data from 2011 to 2017 and identified 1399 individuals who reported sustaining a fracture during the 3 months preceding their survey response. Among these patients, 27% (384 of 1399) were older than 65 years, 77% (1074) were White, 57% (796) were women, and 14% (191) were uninsured. A raw score compiled from 10 food security questions developed by the United States Department of Agriculture was used to determine the odds of 30-day food insecurity for each patient. A multivariate logistic regression analysis was performed to determine factors associated with food insecurity among patients reporting fractures . In the overall sample of National Health Interview Survey respondents, approximately 0.6% (1399 of 239,168) reported a fracture.

RESULTS

Overall, 17% (241 of 1399) of individuals reporting broken bones or fractures in the National Health Interview Survey also reported food insecurity. Individuals reporting fractures were more likely to report food insecurity if they also were aged between 45 and 64 years (adjusted odds ratio 4.0 [95% confidence interval 2.1 to 7.6]; p < 0.001), had a household income below USD 49,716 (200% of the federal poverty level) per year (adjusted OR 3.1 [95% CI 1.9 to 5.1]; p < 0.001), were current tobacco smokers (adjusted OR 2.8 [95% CI 1.6 to 5.1]; p < 0.001), and were of Black race (adjusted OR 1.9 [95% CI 1.1 to 3.4]; p = 0.02).

CONCLUSION

Among patients with fractures, food insecurity screening and routine nutritional assessments may help to direct financially vulnerable patients toward available community resources. Such screening programs may improve adherence to nutritional recommendations in the trauma recovery period and improve the physiologic environment for adequate soft tissue and bone healing. Future research may benefit from the inclusion of clinical nutritional data, a broader representation of high-energy injuries, and a prospective study design to evaluate cost-efficient avenues for food insecurity interventions in the context of locally available social services networks.

LEVEL OF EVIDENCE

Level III, prognostic study.

Concurrent Mental Illness and Financial Barriers to Mental Health Care Among a Nationally Representative Sample of Orthopaedic Trauma Survivors

OBJECTIVES

To understand prevalence and factors associated with concurrent mental illness and financial barriers to mental health care after orthopaedic trauma.

DESIGN

This is a retrospective, cross-sectional study.

SETTING

Interview-based survey was conducted across representative sample of 30,000 US households.

PATIENTS/PARTICIPANTS

The study included 2,309 survey respondents reporting a fracture over the past 3 months, between 2004 and 2017.

INTERVENTION

Screening for financial barriers to mental health care.

MAIN OUTCOME MEASUREMENTS

Prevalence and factors associated with concurrent mental illness and financial barriers to mental health care based on sociodemographic and injury characteristics were the main outcome measurements.

RESULTS

Of the 2309 orthopaedic trauma survivors included in our analysis, 203 patients [7.8%, 95% confidence interval (CI): 6.4%-9.2%] were determined to experience severe mental illness, of whom 54 (25.3%, 95% CI: 18.0%-32.6%) and 86 (40.9%, 95% CI: 31.5%-50.2%) reported financial barriers to counseling and pharmacotherapy, respectively. Factors associated with concurrent severe mental illness and cost barriers to care were 45 to 64 years of age [adjusted odds ratios (AOR) 5.1, 95% CI: 1.7-15, P = 0.004], income below 200% of the Federal Poverty Threshold (AOR 2.5, 95% CI: 1.2-5.3, P = 0.012), and unemployment at the time of injury (AOR 3.9, 95% CI: 1.4-11, P = 0.009).

CONCLUSIONS

Approximately one half of orthopaedic trauma survivors with severe mental illness face financial barriers to some form of mental health services. Younger, minority, and low socioeconomic status patients are most affected. These data suggest the presence of postdiagnosis disparities in mental health access that may be improved through direct provision and subsidization of integrated mental health support services for high-risk populations.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.