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Herrera MM, Tiao J, Rosenberg A, Zubizarreta N, Poeran J, Chaudhary SB. Does Medicare Insurance Mitigate Racial/Ethnic Disparities in Access to Lumbar Spinal Surgery When Compared to Commercial Insurance? Clin Spine Surg 2024; 37:E303-E308. [PMID: 38366343 DOI: 10.1097/bsd.0000000000001576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/29/2023] [Indexed: 02/18/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Compare disparities in lumbar surgical care utilization in Commercially insured versus Medicare patients. SUMMARY OF BACKGROUND DATA While disparities in spinal surgery have been previously described, less evidence exists on effective strategies to mitigate them. Theoretically, universal health care coverage under Medicare should improve health care access. MATERIALS AND METHODS Utilizing National Inpatient Sample data (2003-2018), we included inpatient lumbar discectomy or laminectomy/fusion cases in black, white, or Hispanic patients aged 18-74 years, with Commercial or Medicare insurance. A multivariable Poisson distribution model determined race/ethnicity subgroup-specific rate ratios (RRs) of patients undergoing lumbar surgery compared to their respective population distribution (using US Census data) based on race/ethnicity, region, gender, primary payor, and age (Commercially insured age subgroups: 18-39, 40-54, and 55-64 y; Medicare age subgroup: 65-74 y). RESULTS Of the 2,310,956 lumbar spine procedures included, 88.9%, 6.1%, and 5.0% represented white, black, and Hispanic patients, respectively. Among Commercially insured patients, black and Hispanic (compared to white) patients had lower rates of surgical care utilization; however, these disparities decreased with increasing age: black (RR=0.37, 95% CI: 0.37-0.38) and Hispanic patients (RR=0.53, 95% CI: 0.52-0.54) aged 18-39 years versus black (RR=0.72, 95% CI: 0.71-0.73) and Hispanic patients (RR=0.64, 95% CI: 0.63-0.65) aged 55-64 years. Racial/ethnic disparities persisted in Medicare patients, especially when compared to the neighboring age subgroup that was Commercially insured: black (RR=0.61, 95% CI: 0.60-0.62) and Hispanic patients (RR=0.61, 95% CI: 0.60-0.61) under Medicare. CONCLUSIONS Disparities in surgical care utilization among black and Hispanic patients persist regardless of health care coverage, and an expansion of Medicare eligibility alone may not comprehensively address health care disparities. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Justin Tiao
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Departments of Population Health Science and Policy/Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Saad B Chaudhary
- Institute for Healthcare Delivery Science, Departments of Population Health Science and Policy/Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York
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Tromp J, Teng THK. Regional Differences in the Epidemiology of Heart Failure. Korean Circ J 2024; 54:54.e87. [PMID: 39175346 DOI: 10.4070/kcj.2024.0199] [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: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 08/24/2024] Open
Abstract
Heart failure (HF) epidemiology, patient characteristics, and clinical outcomes exhibit substantial regional variations, reflecting diverse etiologies and health system capacities. This review comprehensively analyses these variations, drawing on data from recent global registries and clinical trials. Our review indicates that ischemic and hypertensive heart diseases are prevalent globally but differ in dominance depending on the region. Notably, regions such as Africa and Latin America show higher instances of HF from hypertensive heart disease and Chagas cardiomyopathy, respectively. Moreover, disparities in age and comorbidity profiles across regions highlight younger populations with HF in lower-income countries compared to older populations in high-income regions. This review also highlights the global disparity in guideline-directed medical and device therapy, underscoring significant underuse in lower-income regions. These insights emphasize the need for targeted HF management strategies considering regional clinical and demographic characteristics to enhance global HF care and outcomes.
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Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Duke-NUS Medical School, Singapore
- National Heart Centre Singapore, Singapore.
| | - Tiew-Hwa Katherine Teng
- National Heart Centre Singapore, Singapore
- School of Allied Health, University of Western Australia, Crawley, WA, Australia
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Yu Y, Liu J, Zhang L, Ji R, Su X, Gao Z, Xia S, Li J, Li L. Perceived Economic Burden, Mortality, and Health Status in Patients With Heart Failure. JAMA Netw Open 2024; 7:e241420. [PMID: 38512256 PMCID: PMC10958235 DOI: 10.1001/jamanetworkopen.2024.1420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/10/2024] [Indexed: 03/22/2024] Open
Abstract
Importance In the face of an emerging heart failure (HF) epidemic, describing the association between perceived economic burden (PEB) and health care outcomes is an important step toward more equitable and achievable care. Objectives To examine the association between PEB and risk of 1-year clinical outcomes and HF-specific health status in patients with acute decompensated HF. Design, Setting, and Participants This prospective, multicenter, hospital-based cohort study prospectively enrolled adult patients hospitalized for acute decompensated HF at 52 hospitals in China from August 2016 to May 2018, with 1-year follow-up. Data were analyzed on June 17, 2022. Exposure Perceived economic burden, categorized as severe (cannot undertake expenses), moderate (can almost undertake expenses), or little (can easily undertake expenses). Main Outcomes and Measures The clinical outcomes of the study were 1-year all-cause death and rehospitalization for HF. Heart failure-specific health status was assessed by the 12-Item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Results Among 3386 patients, median age was 67 years (IQR, 58-75 years) and 2116 (62.5%) were men. Of these patients, 404 (11.9%) had severe PEB; 2021 (59.7%), moderate PEB; and 961 (28.4%), little PEB. Compared with patients with little PEB, those with severe PEB had increased risk of 1-year mortality (hazard ratio [HR], 1.61; 95% CI, 1.21-2.13; P < .001) but not 1-year HF rehospitalization (HR, 1.21; 95% CI, 0.98-1.49; P = .07). The mean (SD) adjusted KCCQ-12 score was lowest in patients with severe PEB and highest in patients with little PEB at baseline (40.0 [1.7] and 50.2 [1.0] points, respectively; P < .001) and at each visit (eg, 12 months: 61.5 [1.6] and 75.5 [0.9] points respectively; P < .001). Patients reporting severe PEB had a clinically significant lower 1-year KCCQ-12 score compared with those reporting little PEB (mean difference, -11.3 points; 95% CI, -14.9 to -7.6 points; P < .001). Conclusions and Relevance In this cohort study of patients with acute decompensated HF, greater PEB was associated with higher risk of mortality and poorer health status but not with risk of HF rehospitalization. The findings suggest that PEB may serve as a convenient tool for risk estimation and as a potential target for quality-improvement interventions for patients with HF.
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Affiliation(s)
- Yuan Yu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiamin Liu
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Zhang
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runqing Ji
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoming Su
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhiping Gao
- Department of General Practice, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuang Xia
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liwen Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Bernard DM, Selden TM, Fang Z. The Joint Distribution Of High Out-Of-Pocket Burdens, Medical Debt, And Financial Barriers To Needed Care. Health Aff (Millwood) 2023; 42:1517-1526. [PMID: 37931199 DOI: 10.1377/hlthaff.2023.00604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Health care financial pressures in the US can manifest themselves in a variety of ways. Some families face high out-of-pocket spending on insurance premiums and medical care relative to income and assets. Some face medical debt that must be paid off over time. And some face delays or go without needed care for reasons involving cost. Whereas prior research has generally focused on these problems separately, a more complete picture of the challenges facing US families can be obtained by examining the joint distribution of these three financial problems. Applying relatively strict definitions of financial problems to data from the 2018-19 Medical Expenditure Panel Survey, we found that 27.0 percent of nonsenior adults lived in families with at least one of the three financial strains assessed. The share of participants facing more broadly defined financial problems was 45.4 percent. Prevalence varied across sociodemographic characteristics, families' health care needs, insurance coverage, and financial resources. The wide distribution of financial strain provides context for ongoing reforms in billing, coverage, and medical debt, as well as for the urgency felt across the country for health care financing reform.
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Affiliation(s)
- Didem M Bernard
- Didem M. Bernard , Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Thomas M Selden
- Thomas M. Selden, Agency for Healthcare Research and Quality
| | - Zhengyi Fang
- Zhengyi Fang, Agency for Healthcare Research and Quality
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Seyoum S, Regenstein M, Benoit M, Dieni O, Willis A, Reno K, Clemm C. Cost burden among the CF population in the United States: A focus on debt, food insecurity, housing and health services. J Cyst Fibros 2023; 22:471-477. [PMID: 36710098 DOI: 10.1016/j.jcf.2023.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 12/09/2022] [Accepted: 01/06/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Advancements in the cystic fibrosis (CF) field have resulted in longer lifespans for individuals with CF. This has led to more responsibility for complex care regimens, frequent health care, and prescription medication utilization that are costly and may not be fully covered by health insurance. There are outstanding questions about unmet medical needs among the U.S. population with CF and how the financial burden of CF is associated with debt, housing instability, and food insecurity. METHODS Researchers developed the CF Health Insurance Survey (CF HIS) to survey a convenience sample of people living with CF in the U.S. The sample was weighted to reflect the parameters of the 2019 Cystic Fibrosis Foundation Patient Registry Annual Data Report, and chi-square tests and multiple logistic regression models were conducted. RESULTS A total of 1,856 CF patients in the U.S. were included in the study. Of these, 64% faced a financial burden: 55% of respondents faced debt issues, 26% housing issues, and 33% food insecurity issues. A third reported at least one unmet medical need: 24% faced unmet prescription needs, 12% delayed or shortened a hospitalization, and 10% delayed or skipped a care center visit as a result of the cost of care. CONCLUSIONS People with CF in the U.S. experience high financial burden, which is associated with unmet medical needs. Income is the biggest risk factor for financial burden for people with CF, with people dually covered by Medicare and Medicaid particularly at risk.
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Affiliation(s)
- Semret Seyoum
- Department of Health Policy and Management, the George Washington University, 950 New Hampshire Ave NW #2, Washington, D.C. 20052, USA
| | - Marsha Regenstein
- Department of Health Policy and Management, the George Washington University, 950 New Hampshire Ave NW #2, Washington, D.C. 20052, USA
| | - Marie Benoit
- Department of Health Policy and Management, the George Washington University, 950 New Hampshire Ave NW #2, Washington, D.C. 20052, USA.
| | - Olivia Dieni
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
| | - Anne Willis
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
| | - Kim Reno
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
| | - Cristen Clemm
- Cystic Fibrosis Foundation, 4550 Montgomery Ave suite 1100 n, Bethesda, MD 20814, USA
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Valero-Elizondo J, Javed Z, Khera R, Tano ME, Dudum R, Acquah I, Hyder AA, Andrieni J, Sharma G, Blaha MJ, Virani SS, Blankstein R, Cainzos-Achirica M, Nasir K. Unfavorable social determinants of health are associated with higher burden of financial toxicity among patients with atherosclerotic cardiovascular disease in the US: findings from the National Health Interview Survey. Arch Public Health 2022; 80:248. [PMID: 36474300 PMCID: PMC9727868 DOI: 10.1186/s13690-022-00987-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 10/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood. METHODS Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence. RESULTS Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features. CONCLUSIONS An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.
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Affiliation(s)
- Javier Valero-Elizondo
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA.
| | - Zulqarnain Javed
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Rohan Khera
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Mauricio E Tano
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Ramzi Dudum
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Isaac Acquah
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Adnan A Hyder
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Julia Andrieni
- Population Health and Primary Care, Houston Methodist Hospital, Houston, TX, USA
| | - Garima Sharma
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J Blaha
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Salim S Virani
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Miguel Cainzos-Achirica
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
| | - Khurram Nasir
- Department of Cardiology, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, 7550 Greenbriar Drive, Houston, TX, 77030, USA
- Center for Outcomes Research, Houston Methodist, 7550 Greenbriar Drive, Houston, TX, 77030, USA
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Espinoza Suarez NR, LaVecchia CM, Morrow AS, Fischer KM, Kamath C, Boehmer KR, Brito JP. ABLE to support patient financial capacity: A qualitative analysis of cost conversations in clinical encounters. PATIENT EDUCATION AND COUNSELING 2022; 105:3249-3258. [PMID: 35918230 DOI: 10.1016/j.pec.2022.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To explore how costs of care are discussed in real clinical encounters and what humanistic elements support them. METHODS A qualitative thematic analysis of 41 purposively selected transcripts of video-recorded clinical encounters from trials run between 2007 and 2015. Videos were obtained from a corpus of 220 randomly selected videos from 8 practice-based randomized trials and 1 pre-post prospective study comparing care with and without shared decision making (SDM) tools. RESULTS Our qualitative analysis identified two major themes: the first, Space Needed for Cost Conversations, describes patients' needs regarding their financial capacity. The second, Caring Responses, describes humanistic elements that patients and clinicians can bring to clinical encounters to include good quality cost conversations. CONCLUSION Our findings suggest that strengthening patient-clinician human connections, focusing on imbalances between patient resources and burdens, and providing space to allow potentially unexpected cost discussions to emerge may best support high quality cost conversations and tailored care plans. PRACTICE IMPLICATIONS We recommend clinicians consider 4 aspects of communication, represented by the mnemonic ABLE: Ask questions, Be kind and acknowledge emotions, Listen for indirect signals and (discuss with) Every patient. Future research should evaluate the practicality of these recommendations, along with system-level improvements to support implementation of our recommendations.
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Affiliation(s)
- Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Centre for Sustainable Health Research, Laval University, Quebec, QC, Canada
| | | | - Allison S Morrow
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Milken Institute School of Public Health, The George Washington University, Washington DC, USA
| | - Karen M Fischer
- Division of Biomedical Statistics and Informatics, Mayo Clinic, MN, USA
| | - Celia Kamath
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, MN, USA.
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Rao BR, Speight CD, Allen LA, Halpern SD, Ko Y, Matlock DD, Moore MA, Morris AA, Scherer LD, Thomson MC, Ubel P, Dickert NW. Impact of Financial Considerations on Willingness to Take Sacubitril/Valsartan for Heart Failure. J Am Heart Assoc 2022; 11:e023789. [PMID: 35723002 PMCID: PMC9238635 DOI: 10.1161/jaha.121.023789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/08/2022] [Indexed: 12/11/2022]
Abstract
Background Sacubitril/valsartan improves health outcomes for heart failure with reduced ejection fraction relative to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, but it carries higher out-of-pocket costs. Neither the impact of cost nor how to integrate cost into medical decisions is well studied. Methods and Results To evaluate the impact of out-of-pocket costs and a novel cost-priming intervention on willingness to take sacubitril/valsartan for heart failure with reduced ejection fraction, participants with self-reported heart disease were surveyed using the online Ipsos Knowledge Panel. Participants were presented with a modified decision aid for sacubitril/valsartan and then, in a 3×2 factorial design, randomly assigned to 1 of 3 cost conditions ($10, $50, or $100/month) and to a control group or cost-priming intervention, defined by being asked questions about their financial situation before learning about the benefits of sacubitril/valsartan. Of the 1013 participants included in the analysis, 85% of respondents were willing to take sacubitril/valsartan at $10, 62% at $50, and 33% at $100 (P<0.0001). In a multivariable logistic regression model, participants were more likely to take sacubitril/valsartan at $10 versus $100 (odds ratio [OR], 14.3 [95% CI, 9.4-21.8]) and $50 compared with $100 (OR, 3.6 [95% CI, 2.5-5.1]). Overall, participants in the cost-primed group were more willing to take sacubitril/valsartan than those not primed to consider their financial situation (63% versus 56%, P=0.04). There was no statistically significant interaction between cost conditions and cost priming. Perceived benefit of sacubitril/valsartan over angiotensin-converting enzyme inhibitors or angiotensin receptor blockers decreased as cost increased but did not vary by cost priming. Conclusions Commonly encountered out-of-pocket costs of sacubitril/valsartan may impact individuals' willingness to take the medication even when recommended by their physicians. Priming individuals to consider personal finances before learning about the drug increased willingness to take sacubitril/valsartan.
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Affiliation(s)
- Birju R. Rao
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
| | - Candace D. Speight
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
| | - Larry A. Allen
- Department of MedicineUniversity of Colorado School of MedicineAuroraCO
| | - Scott D. Halpern
- Palliative and Advanced Illness Research (PAIR) Center and Department of MedicinePennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Yi‐An Ko
- Department of BiostatisticsEmory University Rollins School of Public HealthAtlantaGA
| | - Daniel D. Matlock
- Department of MedicineUniversity of Colorado School of MedicineAuroraCO
| | - Miranda A. Moore
- Department of Family and Preventive MedicineEmory University School of MedicineAtlantaGA
| | - Alanna A. Morris
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
| | - Laura D. Scherer
- Department of MedicineUniversity of Colorado School of MedicineAuroraCO
| | | | - Peter Ubel
- Duke University Fuqua School of BusinessDurhamNC
| | - Neal W. Dickert
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGA
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Wang SY, Valero-Elizondo J, Ali HJ, Pandey A, Cainzos-Achirica M, Krumholz HM, Nasir K, Khera R. Out-of-Pocket Annual Health Expenditures and Financial Toxicity From Healthcare Costs in Patients With Heart Failure in the United States. J Am Heart Assoc 2021; 10:e022164. [PMID: 33998273 PMCID: PMC8483501 DOI: 10.1161/jaha.121.022164] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Heart failure (HF) poses a major public health burden in the United States. We examined the burden of out‐of‐pocket healthcare costs on patients with HF and their families. Methods and Results In the Medical Expenditure Panel Survey, we identified all families with ≥1 adult member with HF during 2014 to 2018. Total out‐of‐pocket healthcare expenditures included yearly care‐specific costs and insurance premiums. We evaluated 2 outcomes of financial toxicity: (1) high financial burden—total out‐of‐pocket healthcare expense to postsubsistence income ratio of >20%, and (2) catastrophic financial burden with the ratio of >40%—a bankrupting expense defined by the World Health Organization. There were 788 families in the Medical Expenditure Panel Survey with a member with HF representing 0.54% (95% CI, 0.48%–0.60%) of all families nationally. The overall mean annual out‐of‐pocket healthcare expenses were $4423 (95% CI, $3908–$4939), with medications and health insurance premiums representing the largest categories of cost. Overall, 14% (95% CI, 11%–18%) of families experienced a high burden and 5% (95% CI, 3%–6%) experienced a catastrophic burden. Among the two‐fifths of families considered low income, 24% (95% CI, 18%–30%) experienced a high financial burden, whereas 10% (95% CI, 6%–14%) experienced a catastrophic burden. Low‐income families had 4‐fold greater risk‐adjusted odds of high financial burden (odds ratio [OR] , 3.9; 95% CI, 2.3–6.6), and 14‐fold greater risk‐adjusted odds of catastrophic financial burden (OR, 14.2; 95% CI, 5.1–39.5) compared with middle/high‐income families. Conclusions Patients with HF and their families experience large out‐of‐pocket healthcare expenses. A large proportion encounter financial toxicity, with a disproportionate effect on low‐income families.
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Affiliation(s)
- Stephen Y Wang
- Department of Internal Medicine Yale-New Haven Hospital New Haven CT
| | | | - Hyeon-Ju Ali
- Department of Cardiology Houston Methodist Houston TX
| | - Ambarish Pandey
- Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | | | - Harlan M Krumholz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Khurram Nasir
- Department of Cardiology Houston Methodist Houston TX
| | - Rohan Khera
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
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Khera R, Valero-Elizondo J, Nasir K. Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions. J Am Heart Assoc 2020; 9:e017793. [PMID: 32924728 PMCID: PMC7792407 DOI: 10.1161/jaha.120.017793] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) has posed an increasing burden on Americans and the United States healthcare system for decades. In addition, ASCVD has had a substantial economic impact, with national expenditures for ASCVD projected to increase by over 2.5‐fold from 2015 to 2035. This rapid increase in costs associated with health care for ASCVD has consequences for payers, healthcare providers, and patients. The issues to patients are particularly relevant in recent years, with a growing trend of shifting costs of treatment expenses to patients in various forms, such as high deductibles, copays, and coinsurance. Therefore, the issue of “financial toxicity” of health care is gaining significant attention. The term encapsulates the deleterious impact of healthcare expenditures for patients. This includes the economic burden posed by healthcare costs, but also the unintended consequences it creates in form of barriers to necessary medical care, quality of life as well tradeoffs related to non‐health–related necessities. While the societal impact of rising costs related to ASCVD management have been actively studied and debated in policy circles, there is lack of a comprehensive assessment of the current literature on the financial impact of cost sharing for ASCVD patients and their families. In this review we systematically describe the scope and domains of financial toxicity, the instruments that measure various facets of healthcare‐related financial toxicity, and accentuating factors and consequences on patient health and well‐being. We further identify avenues and potential solutions for clinicians to apply in medical practice to mitigate the burden and consequences of out‐of‐pocket costs for ASCVD patients and their families.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX.,Center for Outcomes Research Houston Methodist Houston TX
| | - Khurram Nasir
- Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine New Haven CT.,Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX.,Center for Outcomes Research Houston Methodist Houston TX
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Abstract
Background We examined the prevalence of high burdens and barriers to care among adults with heart disease treatment. Methods and Results The participants were aged 18 to 64 years from the Medical Expenditure Panel Survey-Household Component (MEPS-HC) for 2010-2015. High burden is out-of-pocket spending on care and insurance premiums >20% of income. Barriers to care are forgoing and delaying care for financial reasons. Logistic regressions were used to estimate the odds of having high burdens and barriers. Adults treated for heart disease have odds ratios (ORs) of 2.18 (95% CI, 1.91-2.50) for having high burden, 2.51 (95% CI, 2.23-2.83) for forgoing care, and 3.57 (95% CI, 3.8-4.13) for delaying care compared with adults without any chronic condition. Among adults treated for heart disease compared with adults with private group coverage, ORs for having high burdens were significantly lower among those with public insurance (OR: 0.17; 95% CI, 0.10-0.26) or the uninsured (OR: 0.58; 95% CI, 0.36-0.92) and higher among those with private nongroup insurance (OR: 5.30; 95% CI, 3.26-8.61). Compared with adults with private group coverage, ORs for delaying care were 2.07 (95% CI, 1.37-3.12) for those with public insurance, 2.64; 95% CI, 1.70-4.10) for those without insurance, and 2.16 (95% CI, 1.24-3.76) for those with private nongroup insurance. Conclusions Public insurance provides protection against high burdens but not against forgoing or delaying care. Future research should investigate whether and to what extent barriers to care are associated with worse health outcomes and higher costs in the long term.
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Affiliation(s)
- Didem Bernard
- Agency for Healthcare Research and Quality (AHRQ) Rockville MD
| | - Zhengyi Fang
- Social & Scientific Systems, Inc. Silver Spring MD
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