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

Disclosures

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

Abstract and Introduction

Abstract

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

Introduction

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]

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Next Section

Abstract and Introduction
Rationale
Questions
Methods
Results
Conclusions
References

Table 1. Average Financial Distress (FD) and Disability (HAQ-DI) Scores and Correlations for Each Patient Group for All the Patients (N = 113)
Factor	Average FD^a	Average HAQ-DI^a	FD/HAQ-DI Correlation^a	P Value^a
Age (51 ± 17)	—	—	—	—
Sex
Male	3.93	0.44	0.35	0.01
Female	4.26	0.63	0.48	<0.01
Declined to answer	NA	NA	NA	NA
Race
White/Caucasian	3.79	0.48	0.31	0.01
Black or African-American	Min	Min	Min	Min
American Indian	Min	Min	Min	Min
Asian	3.36	0.28	-0.02	0.96
Hispanic	5.08	0.63	0.34	0.36
Pacific Islander	Min	Min	NA	NA
Declined to answer	NA	NA	NA	NA
Income
Less than $50,000	5.89	0.85	0.33	0.08
$50,000-$99,999	3.77	0.63	0.52	0.04
$100,000-$149,999	3.74	0.59	0.36	0.20
$150,000-$199,999	3.85	0.51	0.17	0.49
$200,000-$249,999	3.21	0.29	-0.22	0.57
More than $250,000	2.90	0.18	0.39	0.06
Declined to answer	NA	NA	NA	NA
Education
Some high school	6.5	1.13	0.55	0.34
High school graduate	6.02	0.72	0.51	0.05
Bachelor's degree	3.67	0.48	0.43	<0.01
Trade school	3.60	0.88	0.66	0.15
Master's or other graduate degree	3.82	0.36	0.30	0.13
Doctorate	2.83	0.40	-0.18	0.55
Declined to answer	NA	NA	NA	NA
Insurance
Medicaid	6.53	1.14	0.41	0.27
Medicare	4.44	0.87	0.58	0.00
Health insurance from my employer or my spouse's employer	3.71	0.35	0.20	0.08
Health insurance that I purchase personally out of pocket	Min	Min	NA	NA
Supplemental insurance that I and/or my spouse pays	Min	Min	NA	NA
No health insurance	Min	Min	NA	NA
Declined to answer	NA	NA	NA	NA
Relationship status
Married	3.75	0.49	0.33	0.01
Domestic partnership	5.61	0.84	0.67	0.07
Single, never married	4.23	0.43	0.29	0.18
Single, divorced, or separated	5.30	0.84	0.54	0.07
Single, widowed	Min	Min	NA	NA
Declined to answer	NA	NA	NA	NA
Employment status
Full-time employed	3.44	0.34	0.43	<0.01
Part-time employed	4.65	0.47	0.30	0.36
Retired	3.82	0.83	0.59	<0.01
No work outside the home	4.33	0.47	-0.34
Disabled	7.25	1.27	0.25	0.56
Unemployed	5.50	0.50	-0.84	0.16
Student	4.37	0.28	0.28	0.72
Declined to answer	NA	NA	NA	NA
Financial reserve
Less than 1 mo	6.93	1.07	0.54	0.05
1–2 mo	5.37	0.53	0.07	0.81
3–6 mo	4.58	0.49	0.21	0.38
7–12 mo	3.42	0.40	0.87	<0.01
More than 1 yr	2.77	0.38	0.22	0.13
Declined to answer	NA	NA	NA	NA

FD = InCharge Financial Distress/Financial Well-Being Scale, HAQ-DI = Health Assessment Questionnaire Disability Index
^a Patient subgroups less than three are listed as "Min."
Bolded P values are ≤ 0.05.

Authors and Disclosures

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 and Robin N. Kamal, MD

VOICES Health Policy Research Center, Department of Orthopaedic Surgery (Mr. Mertz, Ms. Eppler, Mr. Thomas, Mr. Alokozai, Dr. Yao, Dr. Amanatullah, Dr. Chou, Dr. Wood, Dr. Safran, Dr. Steffner, Dr. Gardner, and Dr. Kamal), Stanford University, Stanford, CA.

Correspondence to
Dr. Kamal: rnkamal@stanford.edu

Ms. Eppler or an immediate family member is an employee of Patheon and Roche and has stock or stock options held in Patheon and Roche. Dr. Yao or an immediate family member has received royalties from Arthrex; is a member of a speakers' bureau or has made paid presentations on behalf of Arthrex and Trimed; has stock or stock options held in 3D Systems, Elevate Braces, and McGinley Orthopedics; and serves as a board member, owner, officer, or committee member of the American Association for Hand Surgery, the American Society for Surgery of the Hand, and the Arthroscopy Association of North America. Dr. Amanatullah or an immediate family member serves as a paid consultant to BlueJay Mobile Health, DePuy, Exactech, Omni, Stryker, and Zimmer Biomet; has received research or institutional support from Acumed, BlueJay Mobile Health, Stryker, and Zimmer Biomet; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons. Dr. Chou or an immediate family member has received research or institutional support from Arthrex and Cartiva and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the American Orthopaedic Foot and Ankle Society. Dr. Wood or an immediate family member has received royalties from Globus Medical; serves as a paid consultant to Alphatec Spine; and has stock or stock options held in TranS1. Dr. Safran or an immediate family member has received royalties from DJ Orthopaedics, Smith & Nephew, and Stryker; is a member of a speakers' bureau or has made paid presentations on behalf of CONMED, Linvatec, Medacta, and Smith & Nephew; serves as a paid consultant to CONMED, Linvatec, Cool Systems, and Medacta; serves as an unpaid consultant to Cool Systems, Cradele Medicle, Ferring Pharmaceuticals, Biomimedica, and Eleven Blade Solutions; has stock or stock options held in Cool Systems, Cradle Medical, Biomimedica, and Eleven Blade Solutions; has received research or institutional support from Ferring Pharmaceuticals and Smith & Nephew; and serves as a board member, owner, officer, or committee member of the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, and the International Society for Hip Arthroscopy. Dr. Gardner or an immediate family member has received royalties from Synthes; is a member of a speakers' bureau or has made paid presentations on behalf of KCI; serves as a paid consultant to Biocomposites, BoneSupportAB, Conventus, Globus Medical, KCI, Pacira Pharmaceuticals, SI-Bone, StabilizOrtho, and Synthes; has stock or stock options held in Conventus and Imagen Technologies; has received research or institutional support from Medtronic, SmartDevices, SMV Medical, Synthes, and Zimmer Biomet; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Association, the Orthopaedic Research Society, and the Orthopaedic Trauma Association. Dr. Kamal or an immediate family member serves as a paid consultant to Acumed and Heron Therapeutics and as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Mr. Mertz, Mr. Thomas, Mr. Alokozai, and Dr. Steffner.