More ED Visits by Cancer Survivors With Financial Hardships

Roxanne Nelson, RN, BSN

June 22, 2020

Both higher medical and nonmedical financial hardships among cancer survivors are independently associated with more visits to the emergency department (ED), according to new findings.

Additionally, those reporting economic distress were also less likely to be receiving some preventive services, and more likely to have poorer self-rated health.

The findings come from an analysis of data on more than 10,000 cancer survivors who took part in the National Health Interview Survey (2013−2017).

Most of these individuals had some type of health insurance; only 9% had no insurance at all, and more than 96% of cancer survivors aged 65 or older had Medicare.

But even with insurance, patients still experience financial hardship due to coinsurance, deductibles, copay, and other out of pocket expenses, explained lead author Zhiyuan "Jason" Zheng, PhD.

"Many have difficulties in making all of these copayments," said Zheng, a health economist and a principal scientist in the Surveillance and Health Services Research Program at the American Cancer Society (ACS).

"In our modeling, we controlled for health insurance throughout all the adjusted analyses," Zheng told Medscape Medical News. "But we still find that it is common for cancer survivors to report both medical and nonmedical financial hardship."

Even though their analysis did not examine specific pathways between financial hardship and ED visits, "we think that the complexity of care needs for cancer patients with preexisting comorbid conditions may cause a shift in the attention of providers and patients away from comorbid disease management to focus on the cancer treatment," he said. "It is likely that cancer survivors with financial hardship may delay or forgo other care, including primary or specialty care, to save money and only focus on surviving cancer. Therefore, they are more likely to end up in the ED."

Common reasons for cancer-related ED visits included pain, respiratory distress, urinary tract infection, and gastrointestinal issues, the authors note.

The study was published online June 18 in the American Journal of Preventive Medicine.

Higher Burden, More Trips to the ED

Financial toxicity among cancer patients and survivors has been well documented. However, medical financial hardship is experienced across the board by about half of all Americans, the authors note, with cancer survivors being a particularly vulnerable population. In addition to medical costs, survivors are also more likely to be dealing with nonmedical financial hardship, including food insecurity, housing expenses, household bills, and other economic needs.

For their study, Zheng and colleagues examined associations of both medical and nonmedical financial hardships with healthcare utilization and self-rated health, and used the National Health Interview Survey (2013–2017) to identify cancer survivors (aged 18 to 64 years: n = 4939; aged 65 or older: n = 6972).

The team created four levels of medical financial hardship intensities using measures from material, psychological, and behavioral domains, and also created five levels of nonmedical financial hardship intensities with measures in food insecurity and worry about other economic needs.

In this cohort, 66.8% of cancer survivors aged 18-64 had private insurance, 24.2% had public insurance only, and 9% had no insurance.

Medical financial hardships at Level 1 were reported by 32.4% of the younger cohort of cancer survivors (aged 18 to 64) and by 62.8% of the older cohort (aged ≥65); at Level 2 by 28.4% and 23.6%, respectively; at Level 3 by  21.6% and 9.2%, respectively, and at Level 4 by 17.6% and 4.3%, respectively.

Nonmedical financial hardship intensity was reported at Level 1 by 45.8% of the younger cohort and 74.6% of the older patients, respectively; at Level 2 by 27.1% and 16.7% respectively; at Level 3 by 15.6% and 5.7%, respectively; and at Level 4 by 6.1% and 1.6%, respectively.

Overall, the team  found that individuals with higher medical financial hardship intensity had significantly more visits to the ED (Level 4 vs Level 1; aged 18 to 64 years: 42% vs 26.2%, P < .001; aged ≥65 years: 37.6% vs 24.3%, P = .001). The same was true for those with higher nonmedical financial hardship intensity (Level 4 vs Level 1; aged 18 to 64 years: 37.2% vs 27.9%, P = .011).

Higher medical financial hardship also affected the use of preventive services. Cancer survivors with higher medical financial hardship intensity had lower rates of influenza vaccine (Level 4 vs Level 1; aged 18 to 64 years: 45.6% vs 52.5%, P = .036; aged ≥65 years: 64.6% vs 75.6%, P = .008) as well as lower percentages of breast cancer screening (Level 4 vs Level 1; 46.8% vs 61.2%, P = .001).

Similar patterns were observed between higher financial hardship intensities and worse self-rated health in both age cohorts.

Persistent Lower Receipt of Preventive Services

Even though cost sharing for preventive services like cancer screening was eliminated under the Affordable Care Act in most health plans, Zheng pointed out that this study still found that higher medical financial hardship intensity was associated with lower receipt of breast cancer screening and influenza vaccine.

"It is possible that patients with higher socioeconomic status are more aware of the elimination of cost-sharing for preventive services, and this is related to health insurance literacy," he said. "Moreover, low health literacy may also play an important role, because it was consistently associated with lower receipt of mammography screening and influenza vaccine."

"We think improving health literacy and health insurance literacy can help improve cancer screenings and influenza vaccine among those with medical financial hardship, but will require additional research," he added.

Zheng has received grant or research support from AstraZeneca, which is paid through the institution, and is fully employed by the American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector. Coauthor Matthew Banegas has received grant or research support from AstraZeneca, which is paid through the institution. No other financial disclosures were reported.

Am J Prev Med. Published online June 18, 2020. Abstract

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