The Association of Financial Distress With Disability in Orthopaedic Surgery

Kevin Mertz, BS; Sara L. Eppler, MPH; Kevin Thomas, BSE; Aaron Alokozai, BS; Jeffrey Yao, MD; Derek F. Amanatullah, MD, PhD; Loretta Chou, MD; Kirkham B. Wood, MD; Marc Safran, MD; Robert Steffner, MD; Michael Gardner, MD; Robin N. Kamal, MD


J Am Acad Orthop Surg. 2019;27(11):e522-e528. 

In This Article

Abstract and Introduction


Introduction: Increased out-of-pocket costs have led to patients bearing more of the financial burden for their care. Previous work has shown that financial burden and distress can affect outcomes, symptoms, satisfaction, and adherence to treatment. We asked the following questions: (1) Does patients' financial distress correlate with disability in patients with nonacute orthopaedic conditions? (2) Do patient demographic factors affect this correlation?

Methods: We conducted a cross-sectional, observational study of new patients presenting to a multispecialty orthopaedic clinic with a nonacute orthopaedic complication. Patients completed a demographics questionnaire, the InCharge Financial Distress/Financial Well-Being Scale, and the Health Assessment Questionnaire Disability Index. Statistical analysis was done using Pearson's correlation.

Results: The mean score for financial distress was 4.10 (SD, 2.09; scale 1 [low distress] to 10 [high distress]; range, 1.13 to 10.0), and the mean disability score was 0.54 (SD, 0.65; scale 0 to 3; range, 0 to 2.75). A moderate positive correlation exists between financial distress and disability (r = 0.43; P < 0.01). Financial distress and disability were highest for poor, uneducated, Medicare patients.

Conclusions: A moderate correlation exists between financial distress and disability in patients with nonacute orthopaedic conditions, particularly in patients with low socioeconomic status. Orthopaedic surgeons may benefit from identifying patients in financial distress and discussing the cost of treatment because of its association with disability and potentially inferior outcomes. Further investigation is needed to test whether decreasing financial distress decreases disability.

Level of Evidence: Level III prospective cohort


In response to high levels of US healthcare spending, payers and employers have advocated for the use of high deductible plans as one mechanism to shift the burden of medical costs to patients.[1–4] On top of the notable other indirect costs for patients, like transportation fees, caregiver expenses, and missed time at work, increased out-of-pocket costs have led to patients experiencing greater financial distress regarding their health care.[5–11] For example, a study on low-income families with high deductible plans found that they are markedly more likely to postpone or forego treatment because of cost compared with the high-income families.[12] Moreover, one-third of all US patients report increased financial distress because of their health care.[9,13] Increased financial distress can result in harmful, symptomatic effects that lower quality of life, well-being, and quality of care.[9] In oncology, these factors have resulted in decreased patient satisfaction, decreased treatment adherence, and, in some cases, increased mortality.[8,9,11,14–16] One study on patients with cancer found that financial distress was the single strongest predictor of decreased quality of life.[17]