J Alberto Maldonado1,2, Shuangshuang Fu3, Ying-Shiuan Chen1, Chiara Acquati4, K Robin Yabroff5, Matteo P Banegas6, Shine Chang7, Rena M Conti8, Cristina M Checka9, Susan K Peterson10, Pragati Advani11, Kimberly Ku1, Reshma Jagsi12,13, Sharon H Giordano3,14, Robert J Volk3, Ya-Chen T Shih3, Grace L Smith1,3. 1. Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. 2. Departement of Radiation Oncology, University of Texas Medical Branch, Galveston, TX. 3. Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX. 4. Graduate College of Social Work, University of Houston, Houston, TX. 5. American Cancer Society, Atlanta, GA. 6. Kaiser Permanente Center for Health Research, Portland, OR. 7. Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX. 8. Department of Markets, Public Policy, and Law, Boston University School of Business, Boston, MA. 9. Department of Breast Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX. 10. Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX. 11. Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD. 12. Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI. 13. Department of Radiation Oncology, University of Michigan, Ann Arbor, MI. 14. Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
Abstract
PURPOSE: Patients with cancer frequently encounter financial hardship, yet systematic strategies to identify at-risk patients are not established in care delivery. We assessed sensitivity of distress-based screening to identify patients with cancer-related financial hardship and associated care delivery outcomes. METHODS: A survey of 225 patients at a large cancer center assessed cancer-related financial hardship (0-10 Likert scale; highest quintile scores ≥ 5 defined severe hardship). Responses were linked to electronic medical records identifying patients' distress screening scores 6 months presurvey (0-10 scale) and outcomes of missed cancer care visits and bad debt charges (unrecovered patient charges) within 6 months postsurvey. A positive screen for distress was defined as score ≥ 4. We analyzed screening test characteristics for identifying severe financial hardship within 6 months and associations between financial hardship and outcomes using logistic models. RESULTS: Although patients with positive distress screens were more likely to report financial hardship (odds ratio [OR], 1.21; 1.08-1.37; P < .001), a positive distress screen was only 48% sensitive and 70% specific for identifying severe financial hardship. Patients with worse financial hardship scores were more likely to miss oncology care visits within 6 months (for every additional point in financial hardship score from 0 to 10, OR, 1.28; 1.12-1.47; P < .001). Of patients with severe hardship, 72% missed oncology visits versus 35% without severe hardship (P = .006). Patients with worse hardship were more likely to incur any bad debt charges within 6 months (OR, 1.32; 1.13-1.54; P < .001). CONCLUSION: Systematic financial hardship screening is needed to help mitigate adverse care delivery outcomes. Existing distress-based screening lacks sensitivity.
PURPOSE: Patients with cancer frequently encounter financial hardship, yet systematic strategies to identify at-risk patients are not established in care delivery. We assessed sensitivity of distress-based screening to identify patients with cancer-related financial hardship and associated care delivery outcomes. METHODS: A survey of 225 patients at a large cancer center assessed cancer-related financial hardship (0-10 Likert scale; highest quintile scores ≥ 5 defined severe hardship). Responses were linked to electronic medical records identifying patients' distress screening scores 6 months presurvey (0-10 scale) and outcomes of missed cancer care visits and bad debt charges (unrecovered patient charges) within 6 months postsurvey. A positive screen for distress was defined as score ≥ 4. We analyzed screening test characteristics for identifying severe financial hardship within 6 months and associations between financial hardship and outcomes using logistic models. RESULTS: Although patients with positive distress screens were more likely to report financial hardship (odds ratio [OR], 1.21; 1.08-1.37; P < .001), a positive distress screen was only 48% sensitive and 70% specific for identifying severe financial hardship. Patients with worse financial hardship scores were more likely to miss oncology care visits within 6 months (for every additional point in financial hardship score from 0 to 10, OR, 1.28; 1.12-1.47; P < .001). Of patients with severe hardship, 72% missed oncology visits versus 35% without severe hardship (P = .006). Patients with worse hardship were more likely to incur any bad debt charges within 6 months (OR, 1.32; 1.13-1.54; P < .001). CONCLUSION: Systematic financial hardship screening is needed to help mitigate adverse care delivery outcomes. Existing distress-based screening lacks sensitivity.
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