Unlocking the Hidden Dimensions of Cancer Care: Cross-Cultural Adaptation and Feasibility Study of ESAS-FS, Assessing Spiritual Pain and Financial Distress in a Spanish-speaking Population with Advanced Cancer

INTRODUCTION

Spiritual pain and financial distress are two important dimensions of cancer care that are often overlooked. Both dimensions can have a significant impact on the quality of life of patients with cancer and their families.

METHODS

This study conducted a cross-cultural adaptation, feasibility study, and psychometric properties of the Edmonton Symptom Assessment System-Financial and Spiritual (ESAS-FS) in a Spanish-speaking population with advanced cancer. The ESAS-FS is a patient-reported outcome measure that assesses 12 symptoms, including spiritual pain and financial distress.

RESULTS

In the cross-cultural adaptation process, the terms "spiritual pain" and "financial distress" were refined to "sufrimiento espiritual" and "preocupación por asuntos económicos" respectively, with strong professional consensus and high patients' acceptancy (relevant questions 80%, appropriate terms 91%). A cohort of 100 onco-hematologic patients revealed that 70% experienced spiritual pain (mean 2.9/10), while 49% reported financial distress (mean 2.2/10). Symptomatic analyses illustrated significant associations of spiritual pain with various symptoms like fatigue, drowsiness, and depression. Similarly, financial distress correlated notably with drowsiness, depression, and anxiety. Moreover, a distinct correlation was observed between spiritual pain and financial distress.

CONCLUSION

The findings of this study suggest that the ESAS-FS is a valuable tool for assessing spiritual pain and financial distress in Spanish-speaking patients with advanced cancer. The tool can be used to identify patients who are experiencing these dimensions of distress and to provide them with appropriate care.

Financial toxicity and its implication on quality of life in patients attending the palliative care department in a regional cancer centre: An observational study

In India the cancer burden for 2021 was 26.7 million disability-adjusted life years (DALYs), and this is expected to increase to 29.8 million in 2025 (Kulothungan et al., 2022). According to the World Health Organisation (WHO), cancer is a leading cause of death worldwide, accounting for one in six deaths. As per WHO, palliative care is a strategy that assists both adults and children along with their families in dealing with life-threatening illnesses. Currently, only 14% of those in need of pain and palliative (P&P) care receive it globally (WHO, 2020). Financial toxicity (FT) is the term used to describe the negative effects that an excessive financial burden resulting from cancer have on patients, their families, and society (Desai and Gyawali, 2020). Addressing this gap will require significant adjustments to both demand- and supply-side policies to ensure accessible and equitable cancer care in India (Caduff et al., 2019). Measuring FT along with health-related quality of life (HRQoL) represents a clinically relevant and patient-centred approach (de Souza et al., 2017).

AIM AND OBJECTIVE

To estimate FT and its association with quality of life (QoL).

MATERIALS AND METHODS

This was an observational descriptive study conducted among cancer patients recommended for P&P care. Scores were estimated from September 2022 to February 2023 using official tools: the Functional Assessment for Chronic illness Treatment Compressive Score for Financial Toxicity (FACIT-COST) and the European Organisation for Research and Treatment of Cancer (EORTC) Quality of life Questionnaires for Cancer (QLQ30).

RESULTS

From 150 patients (70 males and 80 females, mean age 54.96 ± 13.5 years), 92.6% suffered from FT. Eleven patients (7.3%) were under FT grade 0, 41 (27.3%) were FT grade 1, 98 (65.3%) were FT grade 2, and no patients were under FT grade 3. At criterial alpha 0.05 (95%CI), FT and the global score for HRQoL showed an association. Among inpatient department (IPD) expenses, medication bills contributed the greatest expense at 33%, and among outpatient department (OPD) expenses treatment expenses contributed 50% of the total. Breast cancer (30 cases, 20%) and oral cancer (26 cases, 17.3%) were the most frequent cancers.

CONCLUSION

FT measured using the COST tool showed an association with HRQoL.

POLICY SUMMARY

This paper refers to the insurance policies available for cancer patients irrespective of P&P care treatment.

Development and validation of the Socioeconomic Status Composite Scale (SES-C)

BACKGROUND

Socioeconomic status (SES) is a critical multifactorial determinant of health and plays a significant role in shaping an individual's health outcomes. While a composite scale has been proposed to measure SES in children, to our knowledge, limited composite scales were developed for adults in different contexts, highlighting the need for a comprehensive and valid SES measure to elucidate the relationship between SES and health in this population.

OBJECTIVE

This study aimed to develop and validate a composite scale that measures the socioeconomic status in Lebanon and assess its correlates in a socioeconomic crisis context.

METHODS

An online study was carried out between October and November 2022 across all Lebanese regions. Snowball sampling was used to enroll 448 adults living in Lebanon through a questionnaire created on Google Forms and shared by WhatsApp to a first sample from all geographic areas.

RESULTS

The developed composite scale (SES-C) was found to be reliable and valid. It was based on several aspects of socioeconomic status, i.e., participant education level, family head education level, perceived social class, not being in debt, not receiving financial help, crowding index, participant work status, family head work status, monthly household income, and financial well-being. Furthermore, high SES was significantly associated with married status, older age, alcohol consumption, the absence of chronic disease, easy access to healthcare, private insurance coverage, and the number of rooms in the house in the bivariate analysis. In the multivariable analysis, high SES was significantly associated with age (ORa-1.13; p = 0.011) and easy access to healthcare (ORa = 7.81; p = 0.001) and inversely associated with chronic disease (ORa = 0.17; p = 0.002). Similar results with lower magnitude were found for moderate SES.

CONCLUSION

The study successfully developed and validated a composite scale (SES-C) for measuring the socioeconomic status in Lebanon, taking into account the complexities of the Lebanese context. The scale was found to be reliable and valid, and its results showed significant correlations with various factors such as older age, lower risk of chronic disease, and easy access to healthcare.

Healthcare affordability and effects on mortality among adults with liver disease from 2004 to 2018 in the United States

BACKGROUND & AIMS

Liver disease is associated with substantial morbidity and mortality, likely incurring financial distress (i.e. healthcare affordability and accessibility issues), although long-term national-level data are limited.

METHODS

Using the National Health Interview Survey from 2004 to 2018, we categorised adults based on report of liver disease and other chronic conditions linked to mortality data from the National Death Index. We estimated age-adjusted proportions of adults reporting healthcare affordability and accessibility issues. Multivariable logistic regression and Cox regression were used to assess the association of liver disease with financial distress and financial distress with all-cause mortality, respectively.

RESULTS

Among adults with liver disease (n = 19,407) vs. those without liver disease (n = 996,352), those with cancer history (n = 37,225), those with emphysema (n = 7,937), and those with coronary artery disease (n = 21,510), the age-adjusted proportion reporting healthcare affordability issues for medical services was 29.9% (95% CI 29.7-30.1%) vs. 18.1% (95% CI 18.0-18.3%), 26.5% (95% CI 26.3-26.7%), 42.2% (95% CI 42.1-42.4%), and 31.6% (31.5-31.8%), respectively, and for medications: 15.5% (95% CI 15.4-15.6%) vs. 8.2% (95% CI 8.1-8.3%), 14.8% (95% CI 14.7-14.9%), 26.1% (95% CI 26.0-26.2%), and 20.6% (95% CI 20.5-20.7%), respectively. In multivariable analysis, liver disease (vs. without liver disease, vs. cancer history, vs. emphysema, and vs. coronary artery disease) was associated with inability to afford medical services (adjusted odds ratio [aOR] 1.84, 95% CI 1.77-1.92; aOR 1.32, 95% CI 1.25-1.40; aOR 0.91, 95% CI 0.84-0.98; and aOR 1.11, 95% CI 1.04-1.19, respectively) and medications (aOR 1.92, 95% CI 1.82-2.03; aOR 1.24, 95% CI 1.14-1.33; aOR 0.81, 95% CI 0.74-0.90; and aOR 0.94, 95% CI 0.86-1.02, respectively), delays in medical care (aOR 1.77, 95% CI 1.69-1.87; aOR 1.14, 95% CI 1.06-1.22; aOR 0.88, 95% CI 0.79-0.97; and aOR 1.05, 95% CI 0.97-1.14, respectively), and not receiving the needed medical care (aOR 1.86, 95% CI 1.76-1.96; aOR 1.16, 95% CI 1.07-1.26; aOR 0.89, 95% CI 0.80-0.99; aOR 1.06, 95% CI 0.96-1.16, respectively). In multivariable analysis, among adults with liver disease, financial distress (vs. without financial distress) was associated with increased all-cause mortality (aHR 1.24, 95% CI 1.01-1.53).

CONCLUSIONS

Adults with liver disease face greater financial distress than adults without liver disease and adults with cancer history. Financial distress is associated with increased risk of all-cause mortality among adults with liver disease. Interventions to improve healthcare affordability should be prioritised in this population.

IMPACT AND IMPLICATIONS

Adults with liver disease use many medical services, but long-term national studies regarding the financial repercussions and the effects on mortality for such patients are lacking. This study shows that adults with liver disease are more likely to face issues affording medical services and prescription medication, experience delays in medical care, and needing but not obtaining medical care owing to cost, compared with adults without liver disease, adults with cancer history, are equally likely as adults with coronary artery disease, and less likely than adults with emphysema-patients with liver disease who face these issues are at increased risk of death. This study provides the impetus for medical providers and policymakers to prioritise interventions to improve healthcare affordability for adults with liver disease.

Discussion of "The Asymmetric Impact of COVID-19: A Novel Approach to Quantifying Financial Distress across Industries"

The COVID-19 pandemic crisis and the associated lockdown measures have exerted significantly adverse effects on corporate sectors globally. Archanskaia et al. (2023) provide a novel empirical strategy to timely assess corporate financial distress in the EU. The contribution is two-fold. First, this paper's notion of financial distress considers both the equity position and corporate indebtedness. Second, the methodology proposed in this paper allows the authors to estimate corporate financial distress in the EU at a highly granular level and link micro-level simulations to sectoral macroeconomic outcomes. The methodology employed by Archanskaia et al. (2023) consists of three steps. First, the authors apply a nowcasting model to acquire monthly industrial turnover data. Second, they feed the obtained monthly industrial turnover into a profit-generating process via an accounting identity to estimate monthly firm profits at the firm level. Third, the authors use the estimated firm profits with a snapshot of information on pre-existing liquid assets to deduce the firm-level liquidity needs and the depletion of equity through the focus period during COVID-19. These estimated results on firm equity position and indebtedness enable the authors to quantity corporate financial distress in the EU via various angles (e.g., country-level heterogeneity, industry heterogeneity, and the targeting of COVID support policies). The primary advantage of this approach is that it deals with large datasets at the granular level and produces firm-level results almost in real-time. Therefore, it can help policymaking track the effects of crises over time. However, one can quickly critique this three-step approach for its susceptibility to the usual Lucas critique. That said, since the objective here is to estimate firm-level financial distress, a large structural model being more or less aggregate in nature, though able to mitigate the Lucas critique concern, will encounter significant challenges in estimating firm-level results with the requisite level of granularity offered by the available data. Therefore, I broadly concur with the authors' position that 'the specific contribution of this paper consists in striking a better balance between the need to carry out a multi-country evaluation of the pandemic's effects on industrial activity in a strongly integrated region like the EU and the difficulty of capturing time, industry, and country variation in turnover with sufficient granularity.'

Do business strategies and environmental, social, and governance (ESG) performance mitigate the likelihood of financial distress? A multiple mediation model

This study explores the connection between business strategies, ESG performance, and the probability of bankruptcy. Using a sample comprising 1970 U.S. firm-year observations from 2016 to 2020, this study adopts several techniques to achieve its goals, including the partial least squares structural equation modeling (PLS-SEM) algorithm and additional analyses. The results demonstrate that a firm with a better cost leadership strategy has higher ESG performance. A sound cost leadership strategy and ESG performance negatively influence a firm's likelihood of financial distress. Using a mediating analysis model, we also find that financial and ESG performance mediate and mitigate the probability of experiencing financial distress through a cost leadership strategy, indicating that these are essential factors that cannot be ignored when mitigating bankruptcy probability. Financial performance also mediates and mitigates the probability of experiencing financial distress through the ESG path. This study adds to the existing body of knowledge by revealing the role of sound business strategies and ESG performance in mitigating the likelihood of financial distress, an under-explored topic. It also analyzes the mediation roles of financial and ESG performance to provide significant insights to companies' decision-makers in order to support them in their endeavors toward performance improvement and achieving best practices.

The Covid-19 outbreak, corporate financial distress and earnings management

This study explores the association between the Covid-19 outbreak, corporate financial distress and earnings management practices in China. We investigate whether firms took advantage of the downturn in economic conditions during the pandemic to adjust their earnings using different earnings management techniques. Utilising a sample of 1832 listed firms and underlying theoretical frameworks (i.e., positive accounting and signalling theory), we find that firms were more inclined to manage earnings during the pandemic period. They favoured using the accrual-based rather than the real activity-based earnings management technique. We also find that firms engaged more in income-increasing practices in the shadow of the outbreak. In addition, our results further demonstrate that financially distressed firms were involved in earnings management, particularly accrual-based earnings management. However, compared to privately-owned firms, state-owned enterprises seem to be involved less in earnings management during the Covid-19 pandemic. Findings from this study raise some concerns for policymakers about the credibility of financial reporting information during Covid-19.

Assessment of formal proceedings and out-of-court reorganisation: results from a survey among turnaround professionals in Austria

This study analyses the decision criteria for a specific form of reorganisation in a creditor-friendly bankruptcy system such as that of Austria. From a neoinstitutional perspective, we present different forms of bankruptcy law and the specifics of reorganisation in Austria. Next, we show several distinctive criteria and influencing factors for formal reorganisation and workouts. We group these factors into constitutions and institutional settings, process and handling, and implementation of the reorganisation. Using a sample of 411 survey responses from turnaround professionals, our empirical study analyses the decision criteria for a specific form of reorganisation. We apply a multivariate approach comprising two-sided paired samples Wilcoxon tests to assess the derived hypotheses and a hierarchical cluster analysis. Our results indicate significant differences in the valuation of the two forms: the turnaround professionals rate public perception much higher for out-of-court reorganisation, whereas legal certainty is rated significantly better for formal proceedings. Regarding process and handling, transparency and the handling of blocking positions are arguments for formal reorganisation, whereas flexibility is valuated better for workouts. In terms of implementation, respondents see advantages for out-of-court reorganisation, as it facilitates the implementation of both financial and operational measures. Taxation, the handling of blocking positions, and the improvement of public perception were identified as key development aspects for the legal framework conditions of the various reorganisation forms.

Changes, challenges and support in work, education and finances of adolescent and young adult (AYA) cancer survivors: A qualitative study

PURPOSE

An increasing number of adolescents and young adults (AYA) are becoming cancer survivors and are dealing with long-term effects of the disease and its treatment. We aimed to collect detailed self-reported information about the areas of work, education, and the financial situation of AYA survivors after acute treatment. We further examined sources of support that were perceived as particular helpful.

METHOD

We conducted semi-structured interviews with a sample of 11 AYA cancer survivors (on average 5 years from diagnosis; mean age at diagnosis = 25.7 years) that had been recruited for the AYA-Leipzig longitudinal study. Interviews were transcribed and data were analysed using qualitative content analysis.

RESULTS

The following themes emerged as relevant: (1) career modifications and job loss, (2) career interruptions and delays, (3) uncertainty in the return-to-work process, (4) reduced work ability, (5) discrimination at the workplace, (6) changes in the personal importance of work and (7) financial burdens. Sources of considerable support included relatives as well as German social security institutions.

CONCLUSIONS

Health care providers should address the specific risk of a financial burden and the somewhat complex social legal situation of young adult survivors after cancer diagnosis. AYA cancer survivors need age-specific comprehensive cancer survivorship support programs. These should accompany them in the long term and be targeted to the individual need for career modification or reorientation - even after the completion of cancer treatment and rehabilitation.

Financial toxicity in cancer patients undergoing radiotherapy in a universal health care system - a prospective multicenter study of 1075 patients

PURPOSE

To establish and confirm prevalence as well as risk factors of financial toxicity in a large national cohort of cancer patients undergoing radiotherapy in a universal health care system.

METHODS

We conducted a prospective cross-sectional study offering a patient-reported questionnaire to all eligible cancer patients treated with radiotherapy in 11 centers in Germany during 60 consecutive days. The four-point subjective financial distress question of the EORTC QLQ-C30 was used as a surrogate for financial toxicity. Confirmatory hypothesis testing evaluated the primary study outcomes: overall prevalence of financial toxicity and its association with predefined risk factors. P-values <.05 were considered statistically significant.

RESULTS

Of 2341 eligible patients, 1075 (46%) participated. The prevalence of subjective financial distress (=any grade higher than not present) was 41% (438/1075) exceeding the hypothesized range of 26.04-36.31%. Subjective financial distress was felt "A little" by 26% (280/1075), "Quite a bit" by 11% (113/1075) and "Very much" by 4% (45/1075) of the patients. Lower household income, lower global health status/ quality of life, higher direct costs and higher loss of income significantly predicted higher subjective financial distress per ordinal regression and confirmed these risk factors. Higher psychosocial distress and lower patient satisfaction were significantly associated with higher subjective financial distress in an exploratory ordinal regression model.

CONCLUSION

The overall prevalence of financial toxicity was higher than anticipated, although reported at low or moderate degrees by most affected patients. As we confirmed risk factors associated with financial toxicity, patients at risk should be addressed early for potential support.

The economic impact of the first wave of the pandemic on 50+ Europeans

We analyse the effects of the first wave of the COVID-19 crisis on the economic situation of 50+ Europeans. We construct a financial distress indicator that captures experiencing an income loss, difficulties to make ends meet and the need to postpone payments. We find that education and income before the pandemic has a protective role, and so does being past retirement age. For households under retirement age, instead, the pandemic has exacerbated inequalities. We also investigate whether households report worse difficulties in making ends meet compared to the pre-COVID-19 period. We show that their ability to make ends meet worsens more with income losses during the pandemic compared to losses experienced in the two-year period before the pandemic.

The Validation of the COmprehensive Score for Financial Toxicity (COST) Scale in Greek Language

The aim of this study was to investigate the psychometric properties of the Greek version of FACIT-COST, as well as to assess the levels of financial distress of patients suffering from lung cancer in relation to their quality of life and lung cancer symptom burden. This was a cross-sectional quantitative study. A self-assessment instrument was used to gather the data. The study involved 120 lung cancer patients who were treated using chemotherapy in a day clinic of a General Hospital in Athens. Data were collected with the COST-FACIT-v2 (used to assess the patients' financial toxicity), The 12-item Health Survey (SF-12), and functional Assessment of Cancer Therapy-Lung Symptom Index Questionnaire-7 items-version 4 (FACIT-FACT-LCS). Descriptive statistics as well as exploratory factor analysis performed all the statistical analyses, which were conducted using IBM SPSS Statistics 25 and had p-values with a significance level of 0.05. The majority of the participants were male (68.3%), married or cohabitated (81.3%), and had been diagnosed with microcell cancer (90%). The factor analysis resulted in one factor that interpreted 35% of the total variance. FACT-L (r = 0.365, p < 0.001), physical component SF-12 (r = 0.184, p = 0.045), and mental health component SF-12 (r = 0.268, p = 0.003) were positively correlated to FACIT-OST, as expected. The Greek validated COST-FACIT-v2 is a reliable tool in providing rapid assessment of cancer patients' level of financial distress.

Evaluating the role of financial navigation in alleviating financial distress among young adults with a history of blood cancer: A hybrid type 2 randomized effectiveness-implementation design

BACKGROUND

Young adulthood (YA) is a complex phase of life, marked by key developmental goals, including educational and vocational attainment, housing independence, maintenance of social relationships, and financial stability. A cancer diagnosis during, or prior to, this phase of life can compromise the achievement of these milestones. Studies of adults with cancer have demonstrated that >70% report experiencing financial side-effects, which are associated with increased mortality, diminished health-related quality of life, and forgone medical care. The goal of this project is to evaluate financial distress of YA-aged survivors of blood cancers, and the impact of financial navigation on alleviating this distress.

METHODS

This three-arm, multi-site, hybrid type 2 randomized effectiveness-implementation design (EID) study will be conducted through remote consent, remote data capture and telephone-based/virtual financial navigation. Participants will be aged 18-39, and more than three years from their blood cancer diagnosis. In this six-month intervention, the study will compare the primary outcome of financial distress in three arms: (1) usual care (2) participant-initiated, ad hoc navigation, and (3) study-directed proactive navigation. The study will be evaluated via the five-component Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) outcome strategy with a mixed-methods approach through quantitative assessment of participant-reported financial distress using the Personal Financial Wellness Scale™, as the primary outcome measure, and qualitative assessment through interviews.

CONCLUSION

The study will address many unanswered questions regarding financial navigation within the YA survivor population and will inform the most successful strategies to mitigate financial distress in this vulnerable population.

Legal Weakness, Investment Risks, and Distressed Acquisitions: Evidence from Russian Regions

This paper traces the survival status of 93,260 Russian business firms in the period of 2007-2019 and empirically examines the determinants of the acquisition of financially distressed companies (i.e., distressed acquisitions). We found that, of 93,260 firms, 50,743 failed in management, and among these distressed firms, 10,110 were rescued by acquisition during the observation period. Our empirical results indicate that, in Russian regions, the weakness of the legal system tends to increase the probability of distressed acquisitions, while other socioeconomic risks negatively affect it. These tendencies are common in most industries and regions. It is also revealed that, in the most-developed area, monotown enterprises are more likely than other firms to be bailed out by acquisition after management failure, but it is not always true for the whole federation.

Household financial burden associated with healthcare for older people in Viet Nam: a cross-sectional survey

BACKGROUND

Population ageing and the associated increase in the healthcare needs of older people are putting pressure on the healthcare system in Viet Nam. The country prioritizes healthcare for older people and has developed financial protection policies to mitigate financial hardship due to out-of-pocket health expenditures (OOPHEs) borne by their households. This study examines the level and determinants of the financial burden of OOPHE among households with people aged ≥ 60 years in Viet Nam.

METHODS

A cross-sectional household survey was conducted among a sample of 1536 older people living in 1477 households in three provinces representing the North, Central and South regions of Viet Nam during 2019-2020. The financial outcomes were catastrophic health expenditure (CHE), using WHO's definition, and financial distress due to OOPHE. Multivariate binary logistic regression analysis was employed to determine the factors associated with these outcomes.

RESULTS

OOPHE for older household members accounted for 86.3% of total household health expenditure. Of households with older people, 8.6% (127) faced CHE, and 12.2% (181) experienced financial distress due to OOPHE. Households were at a higher risk of incurring financial burdens related to health expenditures if they had fewer household members; included only older people; were in rural or remote, mountainous areas; and had older members with noncommunicable diseases. There was no significant association between health insurance coverage and financial burden. However, when older people sought tertiary care or private care, the possibility of a household facing CHE increased. Regardless of the type and level of care, health service utilization by older people results in a higher likelihood of a household encountering financial distress.

CONCLUSIONS

This study reveals that OOPHE for older people can impose substantial financial burdens on households, leading them to face CHE and financial distress. This study provides evidence to justify reforming financial protection policies and introducing policy interventions targeted at better protecting older people and their households from the financial consequences of OOPHE. There is also the need to strengthen the grassroots health facilities to provide primary care closer to home at lower costs, particularly for the management of noncommunicable diseases.

Determinants of telemedicine adoption among financially distressed patients with cancer during the COVID-19 pandemic: insights from a nationwide study

PURPOSE

Telemedicine use during the COVID-19 pandemic among financially distressed patients with cancer, with respect to the determinants of adoption and patterns of utilization, has yet to be delineated. We sought to systematically characterize telemedicine utilization in financially distressed patients with cancer during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of nationwide survey data assessing telemedicine use in patients with cancer during the COVID-19 pandemic collected by Patient Advocate Foundation (PAF) in December 2020. Patients were characterized as financially distressed by self-reporting limited financial resources to manage out-of-pocket costs, psychological distress, and/or adaptive coping behaviors. Primary study outcome was telemedicine utilization during the pandemic. Secondary outcomes were telemedicine utilization volume and modality preferences. Multivariable and Poisson regression analyses were used to identify factors associated with telemedicine use.

RESULTS

A convenience sample of 627 patients with cancer responded to the PAF survey. Telemedicine adoption during the pandemic was reported by 67% of patients, with most (63%) preferring video visits. Younger age (19-35 age compared to ≥ 75 age) (OR, 6.07; 95% CI, 1.47-25.1) and more comorbidities (≥ 3 comorbidities compared to cancer only) (OR, 1.79; 95% CI, 1.13-2.65) were factors associated with telemedicine adoption. Younger age (19-35 years) (incidence rate ratios [IRR], 1.78; 95% CI, 24-115%) and higher comorbidities (≥ 3) (IRR; 1.36; 95% CI, 20-55%) were factors associated with higher utilization volume. As area deprivation index increased by 10 units, the number of visits decreased by 3% (IRR 1.03, 95% CI, 1.03-1.05).

CONCLUSIONS

The rapid adoption of telemedicine may exacerbate existing inequities, particularly among vulnerable financially distressed patients with cancer. Policy-level interventions are needed for the equitable and efficient provision of this service.

Rationale and design of Children's Oncology Group (COG) study ACCL20N1CD: financial distress during treatment of acute lymphoblastic leukemia in the United States

BACKGROUND

The study purpose is to describe trajectories of financial distress for parents of children (ages 1-14.9 years) with newly diagnosed acute lymphoblastic leukemia (ALL). The secondary aim is to identify multilevel factors (child, parent, household, treating institution) that influence change in financial distress over time.

METHODS

The study uses a prospective cohort design, repeated measurements, and mixed methods. The settings are Children's Oncology Group (COG) institutions participating in the National Cancer Institute Community Oncology Research Program (NCORP). Eligible participants are English- and/or Spanish-speaking parents or legal guardians (hereafter "parents") of index children. Parents are asked to complete a survey during their child's induction (T1) and maintenance therapy (T2), and near treatment completion (T3). Study surveys include items about (a) the child's cancer and clinical course, (b) parental socio-economic status, financial distress and financial coping behaviors, and (c) household material hardships. At least 15 parents will be invited to participate in an optional semi-structured interview. NCORP institutions that enroll at least one parent must complete an annual survey about institution resources that could influence parental financial distress.

DISCUSSION

The results will inform future interventions to mitigate financial distress for parents of children diagnosed with ALL and could be instructive beyond this disease group.

TRIAL REGISTRATION

This trial was initially registered with the NCI Clinical Trial Reporting Program ID: NCI-2021-03,567 on June 16, 2021. The study can be found on clinicaltrials.gov, Identifier NCT04928599 .

Deep Learning-Based Model for Financial Distress Prediction

Predicting bankruptcies and assessing credit risk are two of the most pressing issues in finance. Therefore, financial distress prediction and credit scoring remain hot research topics in the finance sector. Earlier studies have focused on the design of statistical approaches and machine learning models to predict a company's financial distress. In this study, an adaptive whale optimization algorithm with deep learning (AWOA-DL) technique is used to create a new financial distress prediction model. The goal of the AWOA-DL approach is to determine whether a company is experiencing financial distress or not. A deep neural network (DNN) model called multilayer perceptron based predictive and AWOA-based hyperparameter tuning processes are used in the AWOA-DL method. Primarily, the DNN model receives the financial data as input and predicts financial distress. In addition, the AWOA is applied to tune the DNN model's hyperparameters, thereby raising the predictive outcome. The proposed model is applied in three stages: preprocessing, hyperparameter tuning using AWOA, and the prediction phase. A comprehensive simulation took place on four datasets, and the results pointed out the supremacy of the AWOA-DL method over other compared techniques by achieving an average accuracy of 95.8%, where the average accuracy equals 93.8%, 89.6%, 84.5%, and 78.2% for compared models.

Financial distress and its associated burden in couples coping with an advanced cancer

PURPOSE

In efforts to understand financial distress (FD) associated with advanced cancer care from the perspective of both patients with incurable disease and their spousal caregivers, we assessed FD in both members of the couple, identified symptom and quality of life (QOL) correlates, and examined the potential role of illness communication.

METHODS

Patients undergoing treatment for stage III/IV lung cancer or a grade III/IV primary brain tumor and their spousal caregivers (n = 76 dyads) completed measures of somatic and affective symptoms including FD, physical and mental QOL, and ease of engaging in illness communication. Patients and caregivers additionally rated their perception of each other's symptoms, including FD.

RESULTS

FD was endorsed by both patients (any FD 62.7%; high FD 24%) and spousal caregivers (any FD 64.7%; high FD 32.3%). Self-reported FD was significantly correlated (partial r = .52, p < .001) within couples. FD was associated with greater symptoms of anxiety (r = .29, p = .01; r = .31, p = .01), depression (r = 29, p = 01; r = .39, p = .001), and poorer physical QOL(r =  - .25, p = .03; r =  - .25, p = .001) for patients and caregivers, respectively. For patients, FD was additionally associated with poorer mental QOL(r =  - .44, p < .001). Caregivers accurately perceived patient FD, yet patients tended to underreport their caregiver's FD by almost an entire point (t = 2.8, p = .007). A 3-way interaction (FD X role X illness communication) revealed (b = .40, p = .041) that illness communication moderated the association between FD and physical QOL for spouses so that spouses who reported less ease of illness communication demonstrated a stronger association between financial distress and physical QOL (b =  - 2.08, p < .001) than those reporting greater ease of engaging in illness communication (b = .49, p = .508).

CONCLUSION

In the advanced cancer setting, FD is prevalent in both patients and their spousal caregivers and associated with psychological distress and poor physical QOL. Results suggest that optimal FD assessment should include patients and spouses, and spouse's ease of engaging with illness communication may be a potential target for future intervention studies.

Identifying missing links in the conceptualization of financial toxicity: a qualitative study

Purpose

Financial toxicity can have a major impact on the quality of life of cancer survivors but lacks conceptual clarity and understanding of the interrelationships of the various aspects that constitute financial toxicity. This study aims to extract major drivers and mediators along the pathway from cancer-related costs to subjective financial distress from the patients’ experiences to establish a better understanding of financial toxicity as a patient-reported outcome.

Methods

Qualitative semistructured interviews with 39 cancer patients were conducted in Germany and addressed patient experiences with cancer-related financial burden and distress in a country with a statutory health care system. Transcripts were analyzed using content analysis.

Results

Several aspects of financial burden need to be considered to understand financial toxicity. The assessment of the ability to make ends meet now or in the future and the subjective evaluation of financial adjustments—namely, the burden of applied financial adjustments and the availability of financial adjustment options—mediate the connection between higher costs and subjective financial distress. Moreover, bureaucracy can influence financial distress through a feeling of helplessness during interactions with authorities because of high effort, non-traceable decisions, or one’s own lack of knowledge.

Conclusion

We identified four factors that mediate the impact of higher costs on financial distress that should be addressed in further studies and targeted by changes in policies and support measures. Financial toxicity is more complex than previously thought and should be conceptualized and understood more comprehensively in measurements, including the subjective assessment of available adjustment options and perceived burden of financial adjustments.

Risk of hospital insolvency and its relationship with income and borrowings from banks: a case-control study with large-scale financial data in Japan

Considering the variety of stakeholders surrounding hospitals, hospital financial distress should be understood as a social issue, rather than just a matter involving the hospital owners. The present study aimed to assess Japanese hospital insolvency and related factors based on a nationwide financial dataset, and to identify indicators of the risk of insolvency. The legal financial reports used included a balance sheet and a profit-and-loss statement of hospitals owned by healthcare corporations, representing about 70% of all Japanese hospitals. This case-control study with descriptive analyses was conducted to clarify the financial status of healthcare corporations and to assess associations between specific factors and insolvency. Insolvency was found in 5.9% of healthcare corporations in 2016. Insolvency was significantly associated with operational income per sales (odds ratio, 0.16), and both short- and long-term borrowings per sales (odds ratios: 1.46 and 1.22 in this order). The present study found that 5.9% of Japanese healthcare corporations were insolvent, and hospital profitability and borrowing (both short- and long-term) could be key factors related to preventing hospital insolvency in Japan. To maintain sustainable healthcare services by hospitals, decision makers should consider the risk of insolvency, and balance the amount of borrowings against sales.

Fuel poverty and financial distress

Governments and advocacy groups have drawn attention to the precarious position of those members of society who are unable to attain an adequate level of energy services, i.e. the fuel poor. Concerns have also arisen about the ability of fuel poor individuals to adapt to the hardship recently brought about by the COVID-19 pandemic. This paper contributes to the literature by exploring empirically the link between fuel poverty and financial distress prior to and during the first wave the COVID-19 pandemic. The analysis is based on the most recent longitudinal, nationally representative survey of the United Kingdom, Understanding Society (UKHLS, Wave 10, January 2018-February 2020). After correcting for the effects of potential endogeneity in the variables of interest, our results identify a statistically robust relationship between fuel poverty indicators and self-reported measures of current financial distress, with stronger effects for subjective indicators. The fuel poverty indicators however exert only a limited influence on an individual's expectation of their future financial situation. Our analysis of the first wave of the COVID-19 pandemic also confirms that fuel poverty contributed to financial distress. Our main findings are robust to a suite of specification and sensitivity checks. Our results lead to recommend assessing measures which target fuel poverty on the basis of their potential indirect effect on financial distress.

Characteristics associated with inter-individual variability in financial distress in patients with breast cancer prior to and for 12 months following surgery

PURPOSE

To evaluate for inter-individual differences in financial distress and identify demographic, clinical, and symptom characteristics associated with higher levels of financial distress.

METHODS

Patients (n = 387) were enrolled prior to breast cancer surgery and followed for 12 months. Financial distress was measured using a 0 (no problem) to 10 (severe problem) numeric rating scale. Hierarchical linear modeling was used to evaluate for inter-individual differences in trajectories of financial distress and characteristics associated with financial distress at enrollment and over 12 months.

RESULTS

Patients' mean age was 55.0 (± 11.7) years and the majority underwent breast conservation surgery (80.6%). Mean financial distress score prior to surgery was 3.3 (± 3.4; range 0 to 10). Unconditional model for financial distress demonstrated no significant changes over time (-0.006/month). Younger age, lower income, receipt of an axillary lymph node dissection and adjuvant chemotherapy, and lower attentional function were associated with higher preoperative levels of financial distress.

CONCLUSION

Risk factors identified in this study can be used to inform clinicians regarding the need to initiate financial discussions and social work referrals for some patients. Additional clinical or system level interventions should be considered for vulnerable groups with these risk factors.

A cross-sectional study of financial distress in persons with multimorbidity

BACKGROUND

Financial distress among persons with multimorbidity is an important topic which has been inadequately addressed to date.

OBJECTIVE

We examined the extent of financial distress among persons with multimorbidity, using data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS).

DESIGN

Cross-sectional, population-based study.

PARTICIPANTS

Adults ages ≥ 18 years with multimorbidity.

MAIN MEASURES

Low income and selected social determinants of health that are indicators of financial distress.

KEY RESULTS

Multimorbidity was more common among those with a household income of less than $15,000 per year (P < 0.001) and among those who were 65 years of age or older (P < 0.001). There was an approximately linear increase in the percentage of individuals who had a household income of less than $15,000 or $25,000 per year with increasing number of morbidities. About one-quarter of individuals who had five or more morbidities had a household income of less than $15,000 per year as compared with 4.49% of individuals with no morbidities (P < 0.001). For all of the social determinants of health examined (Couldn't pay bills, didn't have money for food, didn't have money for balanced meals, didn't have enough money to make ends meet, and felt this kind of stress), there was an approximately linear increase in the percentage of individuals with an indicator of financial distress with increasing number of morbidities. Further research is needed examining the prevalence and correlates of financial distress in this population as well effective strategies for ameliorating its impact on the health and wellbeing of these persons.

Financial Toxicity in People Living with Advanced Cancer: A New, Deadly, and Poorly Addressed Effect of Cancer and Necessary Treatment

OBJECTIVES

Advances in cancer treatments have allowed improved outcomes, even with advanced disease. However, this progress has resulted in a new toxic effect termed 'financial toxicity.' Financial toxicity severely impacts quality of life, even among those insured. The purpose of this article is to gain better understanding of this relatively new concept to better care for our patients, presented primarily from a US perspective.

DATA SOURCES

These include medical databases (PubMed, Scopus) and researcher experience.

CONCLUSION

Financial toxicity is highly prevalent in patients with advanced cancer, and it is associated with multiple worsened outcomes. Those with advancing cancer are at accumulating risk of financial toxicity, exacerbated by other known risk factors. The effects of financial toxicity are debilitating, resulting in deleterious physical, psychological, spiritual, and social effects drastically affecting quality of life. Coping strategies such as taking less than prescribed therapy, delays seeking care, and poorly managed comorbid conditions potentially cause increased symptoms and worse outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Careful assessments by multidisciplinary health care teams could allow early intervention, timely referral to health professionals including social work or financial navigators, and provision of emotional support. Further studies are needed to explore solutions on an institutional and national level that can guide health policy and the creation of practice models that can reduce the harm of financial toxicity.

Emerging Understanding About the Impact of Financial Toxicity Related to Cancer: Canadian Perspectives

OBJECTIVE

This article offers an overall summary of the current situation concerning cancer-related financial toxicity from the perspective of Canadian patents and survivors. The focus is on describing the financial effects experienced by the patient and survivor and family, which they attribute to the cancer diagnosis, treatment, and other factors that contribute to their financial distress.

DATA SOURCES

The information was drawn from peer-reviewed research literature generated by Canadian researchers regarding out-of-pockets costs, loss of income, and the impact of financial burden over the past 2 decades. Priority was given to understanding what patients and survivors and caregivers perceived as financial burden and distress (stress and strain).

CONCLUSION

Canadian patients and family members reported financial burden (out-of-pocket costs, loss of income) and financial distress following the diagnosis and treatment of cancer. Heightened distress from financial burden was reported between 38% and 71% within various samples. Patients and survivors indicated the distress and challenges managing the financial situation had a profound impact on their everyday living and quality of life. Many were surprised by the increased costs, given the county's universal health care system. Baseline financial status, competency in managing finances, and lost wages were significant factors in the distress experienced by patients and family members.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses need to be aware of financial toxicity as a potential side effect of cancer. It may emerge during treatment but can extend well beyond the end of treatment. Early screening and assessment followed by dialogue about the potential impact with patients and family members is important. Routine monitoring of distress related to financial toxicity should be part of ongoing care with appropriate referral to relevant recourses as needed.

Predictors of Financial Distress Among Private U.S. Hospitals

BACKGROUND

Hospitals are closing after poor financial performance leaving many patients without access to medical care. Identifying the factors associated with financial distress offers hospitals avenues for potential intervention to avoid bankruptcy and closure.

MATERIALS AND METHODS

We performed a retrospective analysis of private U.S. hospitals' financial information from 2011 to 2018. A mixed effects logistic regression model was used with the primary outcome of hospital financial distress (based on the Altman Z-score).

RESULTS

Our sample included 2,720 private hospitals contributing a total of 20,022 hospital-year observations. The proportion of hospitals experiencing financial distress each year ranged from 22.0% to 24.3%. For-profit status was associated with an increased odds of financial distress (adjusted odds ratio (aOR), 4.36 [95% Confidence Interval (CI) 3.05 - 6.24]) as compared to non-profit status. A higher share of hospital revenue from Medicaid was also associated with increased odds of financial distress (aOR for the highest quartile, 2.28 [95% CI 1.73 - 3.00]) as compared to the lowest quartile. A higher case mix index (aOR for the highest quartile, 0.32 [95% CI 0.23 - 0.46]) and an increased share of hospital revenue from outpatient services (aOR for the highest quartile, 0.34 [95% CI 0.23 - 0.49]) were associated with decreased odds of financial distress as compared to their respective lowest quartiles.

CONCLUSIONS

A significant proportion of private U.S. hospitals experience financial distress. Increasing case complexity and the proportion of patient revenue from outpatient services may represent avenues to avoid financial distress.

The role of financial conditions for physical and mental health. Evidence from a longitudinal survey and insurance claims data

BACKGROUND

Both theory and empirical evidence suggest that financial conditions are influential for mental health and might contribute to physical health outcomes.

METHODS

Using longitudinal survey data and health insurance claims data from 1209 employees in a large U.S. health insurance company, we examined temporal associations between measures of financial safety, financial capability, financial distress, their summary index (financial security) and six subsequently measured mental and physical health outcomes.

RESULTS

We found that financial safety and financial capability were positively associated, while financial distress was negatively associated, with subsequent self-reported measures of physical and mental health, even after controlling for these health measures at baseline and other confounders. Additionally, financial conditions were associated with reduced risk of depression based on health insurance claims data. Financial safety was also associated with anxiety.

CONCLUSIONS

Policy-makers might consider the introduction of more effective measures for ensuring favorable financial conditions as an important contributor to better population health. Furthermore, policy could encourage teaching adequate financial management techniques and the importance of understanding of long-term consequences of financial decisions, as those might be pivotal for health outcomes.

Impact of Covid-19 outbreak on psychological health-The case of Bangladesh

BACKGROUND

The outbreak of COVID-19, a profoundly contagious disease has unnerved the world in a calamitous manner from diverse aspects. The present study ventures to expand the literature by exploring loneliness, social isolation, risk perception, financial distress, and psychological distress amidst the lockdown phase of the general population of Bangladesh.

METHODS

Through an online survey among 474 respondents (between April 17th and April 23rd, 2020), data were collected from the Bangladeshi residents (21 years or above). Descriptive and inferential statistical analyses were conducted using IBM Statistical Package for Social Science (SPSS) and Warp-PLS.

RESULTS

Findings suggest a strong positive correlation among the factors and social isolation, risk perception, financial distress are manifested as the predictors of psychological distress. Besides, females, aged people, and lower-income group are found to be more psychologically distressed.

CONCLUSION

This study yields new insights into the psychological facets of a lower-middle-income earning country, Bangladesh.

The heterogeneous and regressive consequences of COVID-19: Evidence from high quality panel data

Using new data from the first two waves of the Understanding Society COVID-19 Study collected in April and in May 2020 in the UK, we study the labour market shocks that individuals experienced in the first wave of the pandemic, and the steps they and their households took to cope with those shocks. Understanding Society is based on probability samples and the Covid-19 Study is constructed carefully to support valid population inferences. The Covid-19 Study collected novel data on the mitigation strategies that individuals and households employ. Further, prior observation of respondents in the panel allows us to characterize regressivity with respect to pre-pandemic economic positions. Our key findings are that those with precarious employment, aged under 30 and from minority ethnic groups faced the biggest labour market shocks. Almost 50% of individuals have experienced declines in household earnings of at least 10%, but declines are most severe in the bottom pre-pandemic income quintiles. Methods of mitigation vary substantially across groups: borrowing and transfers from family and friends are most prevalent among those most in need.

Ten Years of Marriage and Cohabitation Research in the Journal of Family and Economic Issues

I reviewed the 36 marriage and cohabitation studies from the Journal of Family and Economic Issues articles published between 2010-2019. Nearly all of the studies used quantitative methods, and two-thirds of them used publicly available nationally-representative data. The studies fell into roughly five, unevenly sized groups: family structure, relationship quality, division of labor/employment, money management, and an "other" category. Suggestions for future research include applying some of the important questions within the articles to underrepresented groups, further examining the process of how finances and relationship quality interrelate and doing more applied and translational research.

The impact of the fipronil crisis on the financial performance of Dutch laying hen farms

Background

Illegal use of fipronil as an insecticide in 2017 has caused substantial damage to Dutch laying hen farms. We assessed how the fipronil crisis has affected the financial performance of affected farms as well as unaffected farms. While affected farms faced culling their flocks and lost revenue, unaffected farms benefitted from temporary high egg prices.

Methods

A three-step normative modelling approach is taken using financial statements and a partial budget. The estimations are for a 50,000 laying hen farm facing the fipronil crisis for 5 months. First, a baseline is created by generating an income statement of this laying hen farm representing a ‘normal year’. Second, incremental costs and revenue as a result of the fipronil crisis are estimated. Third, the baseline income statement is updated with the outcomes of the partial budget. This results in two additional income statements that report the net operating result of this farm being unaffected and affected by the fipronil crisis.

Results

While in a normal year this average-sized farm has a net operating result of around 18,000 euros, profitability was estimated to be − 369,000 euros and + 169,000 euros for the affected and unaffected farm due to the crisis respectively. For affected farms, impacts were especially high as there was no government compensation or insurance.

Conclusions

As Dutch farms typically operate as independent family farms, there was also no compensation from other chain actors. The affected farms therefore likely have faced financial distress and have had to increase debt or use their financial reserves for household consumption and restarting the business. Outcomes contribute to discussions around liability claims and cost-benefit assessments of measures to improve the chain food safety and rapid alert systems.

Talking about the Cost of Care: A Critical Component of Shared Decision Making Patient and Provider Perspectives

Transparency about the costs that patients incur is an increasingly important factor in making decisions throughout the course of diagnosis and treatment. Both patients and providers regard honest, informed discussions about these costs as critical to providing person-centered care, but often encounter a range of barriers to initiating and maintaining these conversations. The Patient Advocate Foundation/National Patient Advocate Foundation with partial funding from the Robert Wood Johnson Foundation has conducted both quantitative and qualitative research with patients and providers designed to identify key issues related to cost of care discussions. These include components of financial toxicity for patients, both related to direct costs and to quality of life, as well as questions as to who should initiate these conversations, when they should take place, and what kind of information and training are needed to make these conversations meaningful. This article reports the results of this work with recommendations for providers about how to incorporate cost of care discussions into the normal clinical work flow and patient life flow.

Talking About the Cost of Care: A Critical Component of Shared Decision Making: Patient and Provider Perspectives

INTRODUCTION

Transparency about the costs that patients incur is an increasingly important factor in making decisions throughout the course of diagnosis and treatment. Both patients and providers regard honest, informed discussions about these costs as critical to providing person-centered care, but often encounter a range of barriers to initiating and maintaining these conversations.

METHODS

The Patient Advocate Foundation/National Patient Advocate Foundation with partial funding from the Robert Wood Johnson Foundation has conducted both quantitative and qualitative research with patients and providers designed to identify key issues related to cost of care discussions.

RESULTS

Key issues identified include components of financial toxicity for patients, both related to direct costs and to quality of life, as well as questions as to who should initiate these conversations, when they should take place, and what kind of information and training are needed to make these conversations meaningful.

CONCLUSIONS

This article reports the results of this work with recommendations for providers about how to incorporate cost of care discussions into the normal clinical work flow and patient life flow.

Material-Psychosocial-Behavioral Aspects of Financial Hardship: A Conceptual Model for Cancer Prevention

Risk of cancer increases with age; and socioeconomic factors have been shown to be relevant for (predictive of) cancer risk-related behaviors and cancer early detection and screening. Yet, much of this research has relied on traditional measures of socioeconomic status (SES) to assess socioeconomic circumstances, which limits our understanding of the various pathways through which the socioeconomic environment affects cancer risk. Research on hardship and health suggests that concepts of financial hardship can uncover socioeconomic factors influencing health behaviors over and above traditional SES measures. Thus, consistently including measures of financial hardship in cancer prevention research and practice may help us further explicate the pathway between socioeconomic circumstances and cancer risk-related behaviors and cancer screening among older adults and help us identify intervention and policy targets. We present a conceptual model of financial hardship that can be applied to cancer prevention research among older adults to provide guidance on the conceptualization, measurement, and intervention on financial hardship in this population. The conceptual model advances a research agenda that calls for greater conceptual and measurement clarity of the material, psychosocial, and behavioral aspects of the socioeconomic environment to inform the identification of potentially modifiable socioeconomic factors associated with cancer risk-related behaviors among older adults.

A bibliometric study on intelligent techniques of bankruptcy prediction for corporate firms

Bibliometric analysis is an effective method to carry out quantitative study of academic output to address the research trends on a given area of investigation through analysing existing documents. This paper aims to explore the application of intelligent techniques in bankruptcy predictions so as to assess its progress and describe the research trend through bibliometric analysis over the last five decades. The results indicate that, although there is a significant increase in publication number since the 2008 financial crisis, the collaboration among authors is weak, especially at the international dimension. Also, the findings provide a comprehensive view of interdisciplinary research on bankruptcy modelling in finance, business management and computer science fields.

The authors sought to contribute to the theoretical development of bankruptcy prediction modeling by bringing new knowledge and key insights. Artificial intelligent techniques are now serving as important alternatives to statistical methods and demonstrate very promising results. This paper has both theoretical and practical implications. First, it provides insights for scholars into the theoretical evolution and intellectual structure for conducting future research in this field. Second, it sheds light on identifying under-explored machine learning techniques applied in bankruptcy prediction which can be crucial in management and decision-making for corporate firm managers and policy makers.

Inequalities in Financial Distress, Symptoms, and Quality of Life Among Patients with Advanced Cancer in France and the U.S

BACKGROUND

Financial distress (FD) is common among patients with advanced cancer. Our purpose was to compare the frequency and intensity of FD and its associations with symptom distress and quality of life (QOL) in these patients in France and the U.S.

MATERIALS AND METHODS

In this secondary analysis of two cross-sectional studies, we assessed data on 292 patients who received cancer care at a public hospital or a comprehensive cancer center in France (143 patients) or the U.S. (149 patients). Outpatients and hospitalized patients over 18 years of age with advanced lung or breast or colorectal or prostate cancer were included. Diagnosed cognitive disorder was considered a noninclusion criterion. Advanced cancer included relapse or metastasis or locally advanced cancer or at least a second-line chemotherapy regimen. Patients self-rated FD and assessed symptoms, psychosocial distress, and QOL on validated questionnaires.

RESULTS

The average patient age was 59 years, and 144 (49%) were female. FD and high intensity were reported more frequently in U.S. patients than in French (respectively 129 [88%] vs. 74 [52%], p < .001; 100 [98%] vs. 48 [34%], p < .001,). QOL was rated higher by the U.S. patients than by the French (69 [SD, 18] vs. 63 [SD, 18], p = .003). French patients had more psychological symptoms such as anxiety (8 [SD, 4] vs. 6 [SD, 5], p = .008). Associations were found between FD and U.S. residence, FD and single status (0.907, p = .023), and FD and metastasis (1.538, p = .036). In contrast, negative associations were found between FD and older age (-0.052, p = .003) and FD and France residence (-3.376, p = .001).

CONCLUSION

Regardless of health care system, FD is frequent in patients with advanced cancer. U.S. patients were more likely to have FD than French patients but reported better QOL. Further research should focus on factors contributing to FD and opportunities for remediation.

IMPLICATIONS FOR PRACTICE

Suffering is experienced in any component of the lives of patients with a life-threatening illness. Financial distress (FD) is one of the least explored cancer-related symptoms, and there are limited studies describing its impact on this frail population. This study highlights the high frequency and severity of FD in patients with advanced cancer in the U.S. and France as well as its impact on their physical and emotional symptoms and their quality of life in these different health care systems. It is necessary for all health care providers to explore and evaluate the presence of FD in patients living with life-threatening illnesses.

Cancer survivorship care plans, financial toxicity, and financial planning alleviating financial distress among cancer survivors

Concomitant with the increasing use of cancer care plans has been an increasing awareness of the potential for oncology care to result in long-term financial burdens and financial toxicity. Cancer survivors can benefit from information on support and resources to help them navigate the challenges after acute cancer treatment. While cancer survivorship plans could be a vehicle for patients to receive information on how to mitigate financial toxicity, cancer survivorship plans have typically not dealt with the financial impact of cancer treatment or follow-up care. Embedding information into cancer survivorship plans on how to reduce or avoid financial toxicity presents an opportunity to address a highly prevalent patient need. Patient-centered qualitative studies are needed to assess the type, format, and level of detail of the information provided.

Predicting Financial Distress in Acute Care Hospitals

Hospitals continue to face financial pressures from healthcare reform and heightened competition. In this study, our objective was to quantify the financial distress in acute care hospitals in Texas, applying multivariate logistic regression in a four-year longitudinal analysis. Of the 310 acute care hospitals, 50 (16.1%) were in financial distress in the most recent year, up considerably year over year. Distressed hospitals had fewer beds, lower patient acuity, and less outpatient revenues than those in good financial condition. Administrators should identify business turnaround strategies for combating distress to avoid potential closure.

Financial Distress and Its Associations With Physical and Emotional Symptoms and Quality of Life Among Advanced Cancer Patients

OBJECTIVE

There are limited data on the effects of financial distress (FD) on overall suffering and quality of life (QOL) of patients with advanced cancer (AdCa). In this cross-sectional study, we examined the frequency of FD and its correlates in AdCa.

PATIENTS AND METHODS

We interviewed 149 patients, 77 at a comprehensive cancer center (CCC) and 72 at a general public hospital (GPH). AdCa completed a self-rated FD (subjective experience of distress attributed to financial problems) numeric rating scale (0 = best, 10 = worst) and validated questionnaires assessing symptoms (Edmonton Symptom Assessment System [ESAS]), psychosocial distress (Hospital Anxiety and Depression Scale [HADS]), and QOL (Functional Assessment of Cancer Therapy-General [FACT-G]).

RESULTS

The patients' median age was 60 years (95% confidence interval [CI]: 58.6-61.5 years); 74 (50%) were female; 48 of 77 at CCC (62%) versus 13 of 72 at GPH (18%) were white; 21 of 77 (27%) versus 32 of 72 (38%) at CCC and GPH, respectively, were black; and 7 of 77 (9%) versus 27 of 72 (38%) at CCC and GPH, respectively, were Hispanic (p < .0001). FD was present in 65 of 75 at CCC (86%; 95% CI: 76%-93%) versus 65 of 72 at GPH (90%; 95% CI: 81%-96%; p = .45). The median intensity of FD at CCC and GPH was 4 (interquartile range [IQR]: 1-7) versus 8 (IQR: 3-10), respectively (p = .0003). FD was reported as more severe than physical distress, distress about physical functioning, social/family distress, and emotional distress by 45 (30%), 46 (31%), 64 (43%), and 55 (37%) AdCa, respectively (all significantly worse for patients at GPH) (p < .05). AdCa reported that FD was affecting their general well-being (0 = not at all, 10 = very much) with a median score of 5 (IQR: 1-8). FD correlated (Spearman correlation) with FACT-G (r = -0.23, p = .0057); HADS-anxiety (r = .27, p = .0014), ESAS-anxiety (r = .2, p = .0151), and ESAS-depression (r = .18, p = .0336).

CONCLUSION

FD was very frequent in both groups, but median intensity was double among GPH patients. More than 30% of AdCa rated FD to be more severe than physical, family, and emotional distress. More research is needed to better characterize FD and its correlates in AdCa and possible interventions.

IMPLICATIONS FOR PRACTICE

Financial distress is an important and common factor contributing to the suffering of advanced cancer patients and their caregivers. It should be suspected in patients with persistent, refractory symptom expression. Early identification, measurement, and documentation will allow clinical teams to develop interventions to improve financial distress and its impact on quality of life of advanced cancer patients.