Adverse Financial Outcomes Research Articles

Green investments, green returns: exploring the link between ESG factors and financial performance in real estate

PurposeThe aim of this research paper is to analyze the connection between ESG performance and financial performance within the real estate sector. By focusing on ESG ratings and pillar scores as proxies for ESG performance, the study investigates how these factors impact both profitability and market indicators.Design/methodology/approachWith data sourced from over 680 publicly listed real estate companies, the research employs a fixed effects regression model to analyze the findings. By utilizing this method, the study can assess the impact of governance, environmental and social factors on both the accounting and market performance of real estate companies.FindingsThe outcomes of this study underscore a link between sustainability, particularly environmental aspects and financial performance. However, the study also reveals a contrasting result: governance factors are associated with adverse financial outcomes. Nevertheless, it is important to highlight the limitations as the results present a mixed picture with limited significant findings.Practical implicationsCompanies should prioritize improvements in environment to boost profitability, while they should carefully consider the costs and benefits associated with enhancing their governance structure.Originality/valueBy focusing on this industry and adopting a global perspective, the study addresses a gap in the literature. The research’s innovative approach to utilizing ESG ratings and pillar scores as proxies for ESG performance enhances its originality. Furthermore, the research’s identification of the differing impacts of environmental and governance factors on financial outcomes add novel perspectives to the discourse.

COVID-19 Pandemic Impact on Nursing Homes Financial Performance.

Nursing homes expressed concern about potential severe adverse financial outcomes of COVID-19, with worries extending to the possibility of some facilities facing closure. Maintaining a strong financial well-being is crucial, and there were concerns that the pandemic might have significantly impacted both expenses and income. This longitudinal study aimed to analyze the financial performance of nursing homes during COVID-19 pandemic. Specifically, we examined the impact of the pandemic on nursing home operating margins, operating revenue per resident day, and operating cost per resident day. The study utilized secondary data from various sources, including CMS Medicare cost reports, Brown University's Long Term Care Focus (LTCFocus), CMS Payroll-Based Journal, CMS Care Compare, Area Health Resource File, Provider Relief Fund distribution data, and CDC's NH COVID-19 public file. The sample consisted of 45 833 nursing home-year observations from 2018 to 2021. Fixed-effects regression analysis was employed to assess the impact of the pandemic on financial performance while controlling for various organizational and market characteristics. The study found that nursing homes' financial performance deteriorated during the COVID-19 pandemic. Operating margins decreased by approximately 4.3%, while operating costs per resident day increased by $26.51, outweighing the increase in operating revenue per resident day by about $17. Occupancy rates, payer mix, and staffing intensity were found to impact financial performance. The study highlights the significant financial impact of the COVID-19 pandemic on nursing homes. While nursing homes faced substantial financial strains, the findings offered lessons for the future, underscoring the need for nursing homes to improve the accuracy of their cost reports and enhance financial transparency and accountability.

Caring for Children in Relation to Financial Hardship, Advance Care Planning, and Genetic Testing Among Adolescent and Young Adults with Cancer.

Purpose: When a cancer diagnosis coincides with caring for children, it may influence the financial impacts of cancer and decisions to pursue advance care planning (ACP) or genetic testing. We examined associations between caring for children and financial hardship, ACP, and genetic testing among female adolescent and young adult (AYA) cancer survivors in North Carolina and California. Methods: Participants were diagnosed at ages 15-39 years with breast, melanoma, gynecologic, lymphoma, or thyroid cancer during 2004-2016. We estimated adjusted prevalence differences (aPDs) and ratios (aPRs) for each outcome by child caring status using marginal structural binomial regression models. Results: Among 1595 women ages 19-54 years at survey (median = 7 years since diagnosis), 819 (51.3%) reported that they were caring for children at diagnosis. Women caring for children had a higher prevalence of material financial hardship (e.g., medical debt; 30% vs. 21.9%; aPD = 9%, 95% confidence interval [CI]: 3 to 14; aPR = 1.39, 95% CI: 1.12 to 1.72) but similar levels of psychological financial hardship compared to noncaregivers. Women caring for children were more likely to complete ACPs (42.2% vs. 30.7%; aPD = 9%, 95% CI: 3 to 16; aPR = 1.30, 95% CI: 1.08 to 1.57). Among the 723 survivors of breast, endometrial, and ovarian cancer, the prevalence of genetic testing was higher among women caring for children (89%) than noncaregivers (81%); this difference was not statistically significant. Conclusion: Women caring for children at diagnosis may be at elevated risk for adverse financial outcomes and may benefit from additional financial navigation support. Childcare responsibilities may further complicate health decision-making for AYAs diagnosed with cancer.

Patient adverse financial outcomes before and after COVID-19 infection.

Adverse financial outcomes after COVID-19 infection and hospitalization have not been assessed with appropriate comparators to account for other financial disruptions of 2020-2021. Using credit report data from 132,109 commercially insured COVID-19 survivors, we compared the rates of adverse financial outcomes for two cohorts of individuals with credit outcomes measured before and after COVID-19 infection, using an interaction term between cohort and hospitalization to test whether adverse credit outcomes changed more for hospitalized than nonhospitalized COVID-19 patients. Covariates included age group, gender, and several area-level social determinants of health. Adverse financial outcomes were significantly more common after COVID-19 infection than before COVID-19 infection, with greater increases among those hospitalized with COVID-19 (5-8 percentagepoints) than among nonhospitalized patients (1-3 percentage points). Future work examining longitudinal financial outcomes before and after COVID-19 infection is needed to determine the causal mechanisms of this association to reduce financial hardship from COVID-19 and other conditions.

Financial Toxicity and Its Association With Health-Related Quality of Life Among Partners of Colorectal Cancer Survivors

Partners of colorectal cancer (CRC) survivors play a critical role in diagnosis, treatment, and survivorship. While financial toxicity (FT) is well documented among patients with CRC, little is known about long-term FT and its association with health-related quality of life (HRQoL) among their partners. To understand long-term FT and its association with HRQoL among partners of CRC survivors. This survey study incorporating a mixed-methods design consisted of a mailed dyadic survey with closed- and open-ended responses. In 2019 and 2020, we surveyed survivors who were 1 to 5 years from a stage III CRC diagnosis and included a separate survey for their partners. Patients were recruited from a rural community oncology practice in Montana, an academic cancer center in Michigan, and the Georgia Cancer Registry. Data analysis was performed from February 2022 to January 2023. Three components of FT, including financial burden, debt, and financial worry. Financial burden was assessed with the Personal Financial Burden scale, whereas debt and financial worry were each assessed with a single survey item. We measured HRQoL using the PROMIS-29+2 Profile, version 2.1. We used multivariable regression analysis to assess associations of FT with individual domains of HRQoL. We used thematic analysis to explore partner perspectives on FT, and we merged quantitative and qualitative findings to explain the association between FT and HRQoL. Of the 986 patients eligible for this study, 501 (50.8%) returned surveys. A total of 428 patients (85.4%) reported having a partner, and 311 partners (72.6%) returned surveys. Four partner surveys were returned without a corresponding patient survey, resulting in a total of 307 patient-partner dyads for this analysis. Among the 307 partners, 166 (56.1%) were aged younger than 65 years (mean [SD] age, 63.7 [11.1] years), 189 (62.6%) were women, and 263 (85.7%) were White. Most partners (209 [68.1%]) reported adverse financial outcomes. High financial burden was associated with worse HRQoL in the pain interference domain (mean [SE] score, -0.08 [0.04]; P = .03). Debt was associated with worse HRQoL in the sleep disturbance domain (-0.32 [0.15]; P = .03). High financial worry was associated with worse HRQoL in the social functioning (mean [SE] score, -0.37 [0.13]; P = .005), fatigue (-0.33 [0.15]; P = .03), and pain interference (-0.33 [0.14]; P = .02) domains. Qualitative findings revealed that in addition to systems-level factors, individual-level behavioral factors were associated with partner financial outcomes and HRQoL. This survey study found that partners of CRC survivors experienced long-term FT that was associated with worse HRQoL. Multilevel interventions for both patients and partners are needed to address factors at individual and systemic levels and incorporate behavioral approaches.

Thyroid nodules: Global, economic, and personal burdens.

Thyroid nodules have garnered attention due to changes in population surveillance systems and rising concerns about the associated financial burden on healthcare systems, payers, and patients. In this review, we find that prevalence rates vary widely based on method of detection and may particularly pronounced in asymptomatic patients undergoing routine screening. Incidence rates may be particularly rising in lower-income and middle-income countries and may be declining in higher-income countries. Despite high incidence rates, survival rates continue to be as high as 97% for papillary thyroid cancer. Over the last few decades, thyroid nodule workup and management has grown more sophisticated with the advent of fine-needle aspiration biopsy, specialized biomarkers, and molecular testing. However, gaps remain in risk stratification that can lead to substantial costs of care. Certain molecular tests, such as the Afirma Gene Sequencing Classifier can lead to a cost per diagnosis of $17,873 while achieving only mild decreases in diagnostic lobectomies for patients (11.6% to 9.7% in one study). Out-of-pocket costs associated with thyroid nodule management continue to drive significant financial toxicity for patients, especially for individuals with thyroid cancer. Financial toxicity has been defined as a term that describes how direct and indirect medical costs of cancer care strain patients and households via decreased income, assets, and spending on basic necessities. Recent studies suggest that such toxicity can lead to adverse financial outcomes, such as foreclosure and bankruptcy. Additional cost-effectiveness analyses are needed to improve existing thyroid nodule management systems and new clinical tools are needed to avoid unnecessary workup and management.

Association of Stroke and Cerebrovascular Pathologies With Scam Susceptibility in Older Adults

Scam susceptibility is associated with adverse financial and health outcomes, including an increased risk of cognitive decline and dementia. Very little is known about the role of cerebrovascular pathologies with scam susceptibility. To examine the association of diverse cerebrovascular pathologies (globally and regionally) with scam susceptibility. This clinical-pathological cohort study included participants from 2 ongoing studies of aging that began enrollment in 1994 and 1997. In 2010, participants were enrolled in the decision-making and behavioral economics substudy and were followed up for a mean (SD) of 3.4 (2.6) years prior to death. From 1365 older persons with clinical evaluations, 69 were excluded for having dementia at baseline. From 538 older persons who died, 408 had annual assessments for scam susceptibility, cardiovascular risk burden, and cognitive function and consented to brain donation for detailed neuropathologic examination. Data were analyzed from June 2021 through September 2022. Neuropathologic examination identified the presence of macroscopic and microscopic infarcts, atherosclerosis, arteriolosclerosis, cerebral amyloid angiopathy, and common neurodegenerative pathologies (Alzheimer disease, limbic-predominant age-related transactive response DNA-binding protein 43 encephalopathy, and Lewy bodies). There was a total of 408 participants. The mean (SD) age at death was 91 (6.1) years, the mean (SD) amount of education was 15.6 (3.1) years, and 297 (73%) were women. Participants included 4 Latino individuals (1%), 7 non-Latino Black individuals (2%), and 397 non-Latino White individuals (97%). The frequency of participants with macroscopic infarcts was 38% (n = 154), microinfarcts was 40% (n = 163), and moderate to severe vessel disease; specifically, atherosclerosis was 20% (n = 83), arteriolosclerosis was 25% (n = 100), and cerebral amyloid angiopathy was 35% (n = 143). In linear regression models adjusted for demographics and neurodegenerative pathologies, macroscopic infarcts were associated with greater scam susceptibility (estimate [SE], 0.18 [0.07]; P = .009). This association persisted after adjusting for cardiovascular risk burden and global cognition. Regionally, infarcts localized to the frontal, temporal, and occipital lobes and thalamus were associated with greater scam susceptibility. Neither arteriosclerosis, atherosclerosis, cerebral amyloid angiopathy, nor microinfarcts were associated with scam susceptibility. Cerebrovascular pathologies, specifically cerebral infarcts, is linked with greater scam susceptibility in older adults, independent of common neurodegenerative diseases such as Alzheimer disease. Future studies examining in vivo magnetic resonance imaging markers of cerebrovascular pathologies with scam susceptibility and related decision-making outcomes will be important.

Insurance Subsidies, the Affordable Care Act, and Financial Stability

AbstractThis paper measures the effects of subsidies in the Affordable Care Act on adverse financial outcomes using administrative tax data and credit data on financial outcomes. Using a difference‐in‐differences design with propensity score reweighting, I find that at $100 per capita, ACA premium tax credits and cost‐sharing reduction subsidies reduced consumer bankruptcies and severe auto delinquency by 8 percent and 7 percent, respectively, and substantially reduced right‐tail delinquent debt and third‐party collections. The value of recipients’ risk protection against medical debt payments amounts to approximately 16 to 21 percent of the cash costs of the subsidies, while the subsidies provided substantial indirect transfers to external parties.

Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

The bidirectional association between health and financial stability is increasingly recognized. To describe the association between chronic disease burden and patients' adverse financial outcomes. This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan. Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders). Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt. The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions. This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.

Selected Articles from This Issue

Whether neighborhood obesogenic factors are associated with prostate cancer risk has not been studied. DeRouen and colleagues examined neighborhood socioeconomic status and obesogenic environment factors (urbanicity, mixed-land development, unhealthy food environment, and parks) for associations with risk of prostate cancer among 41,563 African American, Japanese American, Latino, and White males in the Multiethnic Cohort Study. The study is unique in assessing neighborhood factors and prostate cancer risk while considering disease aggressiveness as well as individual-level sociodemographic, behavioral, and prostate cancer risk factors. Independent associations of obesogenic environment factors with prostate cancer risk varied by race, ethnicity, nativity, and disease aggressiveness.Modifiable lifestyle-related factors heighten the risk and severity of COVID-19 in patients with cancer. Whether exercise lowers susceptibility or severity is not known. Bliss and colleagues examined the relationship between exercise and COVID-19 risk and severity in 944 cancer patients. In this single institution study, cancer patients meeting national exercise guidelines had lower susceptibility to COVID-19 relative to their sedentary counterparts even after adjustment for important clinical and epidemiologic covariates. Exercise reduced the risk of COVID-19 infection in patients, but not its severity. This data adds to the growing evidence base of exercise benefit following a cancer diagnosis.Adolescent and young adult (AYA) women with cancer can face additional financial stressors from fertility services that are often not covered by insurance. Meernik and colleagues surveyed AYA cancer survivors in North Carolina and California to examine whether women who used fertility preservation had increased financial hardship. Fertility preservation was associated with 1.5 times the likelihood of borrowing money, going into debt, or filing for bankruptcy; and 12% of women who used fertility preservation reported debt of ≥$25,000 (vs. 5% in the referent group). More widespread insurance coverage could expand access to fertility services and decrease adverse financial outcomes after cancer.As alcohol consumption has a J-shape association with colorectal cancer risk (CRC), non-drinking and heavy drinking are both risk factors for CRC. In this study, individual-level data was pooled to compare non-drinkers (&lt;=1 g/day) and heavy drinkers (&gt;28 g/day) with light-to-moderate drinkers (1-28 g/day) in gene-alcohol interaction analyses. This study suggests that the association with CRC in 10q24.2/COX15 was strongest in non-drinkers. Jordahl, Shcherbina, and colleagues also identified rs1318920 as the putative causal regulatory variant for the region. The study identifies multifaceted evidence of a possible functional effect for rs1318920.

Out-of-pocket payments for complementary medicine following cancer and the effect on financial outcomes in middle-income countries in southeast Asia: a prospective cohort study

Complementary medicine, which refers to therapies that are not part of conventional medicine, comprising both evidence-based and non-evidence-based interventions, is increasingly used following a diagnosis of cancer. We aimed to investigate out-of-pocket spending patterns on complementary medicine and its association with adverse financial outcomes following cancer in middle-income countries in southeast Asia. In this prospective cohort study, data on newly diagnosed patients with cancer were derived from the ASEAN Costs in Oncology (ACTION) cohort study, a prospective longitudinal study in 47 centres located in eight countries in southeast Asia. The ACTION study measured household expenditures on complementary medicine in the immediate year after cancer diagnosis. Participants were given cost diaries at baseline to record illness-related payments that were directly incurred and not reimbursed by insurance over the 12-month period after study recruitment. We assessed incidence of financial catastrophe (out-of-pocket cancer-related costs ≥30% of annual household income), medical impoverishment (reduction in annual household income to below poverty line following subtraction of out-of-pocket cancer-related costs), and economic hardship (inability to make necessary household payments) at 1 year. Between March, 2012, and September, 2013, 9513 participants were recruited into the ACTION cohort study, of whom 4754 (50·0%) participants were included in this analysis. Out-of-pocket expenditures on complementary medicine were reported by 1233 households. These payments constituted 8·6% of the annual total out-of-pocket health costs in lower-middle-income countries and 42·9% in upper-middle-income countries. Expenditures on complementary medicine significantly increased risks of financial catastrophe (adjusted odds ratio 1·52 [95% CI 1·23-1·88]) and medical impoverishment (1·75 [1·36-2·24]) at 12 months in upper-middle-income countries only. However, the risks were significantly higher for economically disadvantaged households, irrespective of country income group. Integration of evidence-supported complementary therapies into mainstream cancer care, along with interventions to address use of non-evidence-based complementary medicine, might help alleviate any associated adverse financial impacts. None.

Abstract PO-087: Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors

Abstract Background: Increasing attention is being paid to understanding and addressing the financial consequences of cancer and cancer treatment; however, in addition to the direct and indirect costs of cancer care, survivors with few financial resources also face social needs such as food insecurity and housing instability. On average, young adults have fewer financial resources than older adults, placing them at risk for adverse financial outcomes due to cancer, including unmet social needs. The purpose of this study is to estimate associations between young adult age at diagnosis and prevalence of social needs among African American cancer survivors. Methods: We utilized data from 3,241 participants in the Detroit Research on Cancer Survivors (ROCS) cohort. African American adults were invited to participate if they were between the ages of 20-79 at diagnosis with breast, colorectal, lung, or prostate cancer since January 1, 2013; or diagnosed with endometrial cancer (ages 20-79) or any other cancer (ages 20-49) since January 1, 2016. Cases were identified through the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry. Participants self-reported several forms of unmet social needs, including food insecurity, recent utility shut-offs, housing instability, inability to get medical care due to lack of transportation, and whether they generally felt safe in their neighborhood. Modified Poisson models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for social needs by age at diagnosis (20-39 vs. 65+) and tests for trend by 4-level age (20-39, 40-54, 55-64, 65+), controlling for demographic, socioeconomic, and cancer-related factors. Results: Overall, 32% of ROCS participants reported experiencing social needs, and prevalence was inversely associated with age at diagnosis such that 48% of survivors diagnosed as young adults reported any social needs compared with 22% of those diagnosed as older adults (PRadjusted: 2.3, 95% CI: 1.8-2.9; ptrend&amp;lt;0.001). Associations between young adult age at diagnosis and social needs were particularly high for utility shutoffs (PRadjusted: 4.7, 95% CI: 2.8-7.8) and food insecurity (PRadjusted: 3.4, 95% CI: 2.3-4.9) compared with those diagnosed as older adults. Young adults also reported substantially higher prevalence of not feeling safe in their neighborhood (PRadjusted: 2.8, 95% CI: 1.7, 4.6), housing instability (PRadjusted: 2.7, 95% CI: 1.7-4.5), and going without medical care due to lack of transportation (PRadjusted: 2.0, 95% CI: 1.2-3.3). There was an inverse association with age and all social needs examined (all ptrend&amp;lt;0.001). Conclusions: Each unmet social need considered was at least twice as common among African American cancer survivors diagnosed as young adults compared with those diagnosed when they were 65 or older. Young adults often have fewer financial resources compared older adults and should be prioritized in the development of interventions aimed at improving financial outcomes among cancer survivors. Citation Format: Theresa A. Hastert, Julie J Ruterbusch, Jean A. McDougall, Jamaica R.M. Robinson, Shaila M. Strayhorn, Andrew Abdallah, Gowri Chandrashekar, Ann G. Schwartz. Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-087.

Prevalence and Risk-Factors for Financial Burden in Patients with Chronic Graft-Versus-Host Disease: A Cross-Sectional Survey from the Chronic Gvhd Consortium

IntroductionAllogeneic hematopoietic cell transplantation (HCT) patients with chronic GVHD (cGVHD) are at risk for financial burden due to expenses from continued intensive medical care and disability preventing return to work. Understanding the financial impact of cGVHD is essential to develop ways to improve the overall well-being of affected patients. Using data from the Chronic GVHD Consortium, we describe prevalence and risk-factors for financial burden and its association with patient reported outcomes.MethodsA cross-sectional questionnaire about information regarding financial concerns, household income, employment status, insurance and out-of-pocket expenses was completed by 182 patients (response rate=66%) enrolled on a multi-center observational study to develop and validate endpoint measures for cGVHD treatment. Financial burden was defined as reporting ≥1 of the following: difficulty paying medical bills, not having enough money at the end of the month, reducing spending on home/ leisure activities, using retirement savings, borrowing money or selling assets (e.g. house/car), or declaring bankruptcy. A multivariable logistic regression analysis was performed to determine the association of socio-demographic (age, gender, race, insurance, employment, income and education) and clinical factors including cGVHD severity and physical and mental functioning (measured by SF-36) with financial burden.ResultsMedian age was 56 years (range 12-79) and 88% of the patients were White. Median time from HCT to onset of cGVHD was 7.5 months and median time from enrollment to completion of the financial survey was 12.9 months. At diagnosis, physician reported cGVHD severity was mild in 22%; moderate in 53%, and severe in 22% patients. 48% patients had a college or post-graduate degree and 69% were in a partnered relationship. Median physical and mental component scores at enrollment were 39.2 (range 15.8-57.9) and 50.4 (range 7.1-68.0) respectively (general population score-50, and lower scores indicate worse functioning). All except one patient had health insurance at the time of the survey (49% private and 43% Medicaid/Medicare). Patients reporting annual household income <$25,000 increased from 10% at enrollment to 20% at the time of survey completion. 23% and 39% of patients reported spending >$500 in the last 3 months on healthcare related non-medical and medical out-of-pocket costs, respectively. 64% of the respondents reported at least one financial challenge: 24% had difficulty paying medical bills, 28% reported not having enough money at the end of the month, 49% reduced spending on utilities and other expenses, 31% used retirement savings and 16% borrowed money or sold assets. Bankruptcy rate was <1%. The determinants for financial burden included losing/changing insurance (8%), inability to return to work (40%), frequent physician visits (32%) and need for multiple medications/treatments (41%). 46% and 51% of patients >1 year out from HCT had made ≥4 visits to their transplant center clinic or their hematologist in the last 6 months, respectively. 32% received assistance from friends/family/fundraisers and 11% utilized resources suggested by transplant social workers to help with finances. 34% had faced insurance difficulties such as delayed/denied coverage for specific treatments for cGVHD (65% for medications and 38% for labs/procedures, such as extra corporeal photopheresis), and this experience was correlated with reporting financial burden (p=0.05). The multivariable model showed unemployment (OR 3.82; p=0.02) and low household income (OR 11.8; p=0.009 for <$25,000 vs ≥$75,000) to be risk factors for financial burden. There was no association of insurance type, cGVHD severity and physical and mental functioning with financial burden.ConclusionsA significant proportion of cGVHD patients experience financial hardship despite having health insurance coverage. A third had difficulty with insurance coverage for recommended cGVHD treatments. Future research should investigate potential interventions to help at-risk patients and prevent long-term adverse financial outcomes in this vulnerable group. Policy changes are needed to ensure adequate long-term coverage for HCT patients, especially those with cGVHD who are at high risk for poor financial outcomes and possibly worse health outcomes if they are not able to afford recommended care. DisclosuresKhera:Novartis: Consultancy. Jagasia:Janssen: Consultancy, Research Funding; Mallinckrodt: Consultancy; Therakos: Consultancy, Research Funding. Chen:Immudex: Research Funding. Flowers:Pharmacyclics: Consultancy. Arora:Takeda Oncology: Consultancy. Majhail:Sanofi: Honoraria; Anthem, Inc.: Consultancy. Lee:Amgen: Other: One-time advisory board member; Mallinckrodt: Honoraria; Bristol-Myers-Squibb: Other: One-time advisory board member; Kadmon: Other: One-time advisory board member.

Long-term financial outcomes and quality of life in partners of colorectal cancer survivors.

7048 Background: Many patients with colorectal cancer face financial toxicity, but little is known about financial outcomes among their partners. Moreover, virtually nothing is known about associations between partners’ quality of life and their financial outcomes. Methods: In 2019 we surveyed patients who, in 2014-18, underwent resection of Stage III colorectal cancer and were seen at a community oncology practice, an academic cancer center, or reported to Georgia SEER (current RR 46%). Patients gave a separate survey to their partner. 254 partners (68% RR) completed surveys. Partners were asked about financial impacts of the patient’s cancer. Partners’ quality of life (QOL) was measured with the PROMIS global health scale. Multivariable regression analyses of 3 partner-reported outcomes (1. Perception that their financial status is worse off, 2. Substantial worry about finances, 3. Debt related to patients’ cancer) were generated to assess associations between each outcome and key partner and patient variables, and associations between partners’ QOL and financial outcomes. Results: Among partners, 55% were &lt; age 65, 64% female, 86% white, and 27% had &lt; high school education. 61% were employed at time of patient’s diagnosis; 38% of those missed 7-30 days work and 13% missed &gt; 1 month work due to the patient’s cancer. 66% patients were employed at diagnosis. Among those, 34% were no longer working at the time of survey. In 14% dyads only the patient was working at diagnosis and among those, 50% were no longer working at the time of survey. 32% partners reported their financial status is worse off, 36% reported substantial worry about finances, and 28% reported current debt, all due to the patient’s cancer. After adjustment for partner and patient variables, partners of patients further out from diagnosis and partners of patients who were working at diagnosis were more likely to report substantial worry. Partners &lt; age 50, with &lt;high school education, with &gt;1 comorbid condition, and partners of patients who were working at diagnosis were more likely to report debt (all p &lt; 0.05). Endorsing each of the 3 financial outcomes was associated with lower QOL among partners, after adjustment for partner and patient variables (all p &lt; 0.01). Conclusions: Nearly 1/3 of partners of survivors of colorectal cancer reported long-term adverse financial outcomes due to the patient’s cancer. Partners of patients working at the time of diagnosis were more likely to report substantial worry and debt, perhaps because many patients who were working at diagnosis are no longer working in the survivorship period.

The Impact of Hematopoietic Stem Cell Transplantation on Work and Productivity Loss in Patients with Acute Leukemia: Results from a Rapid Review

Introduction: Acute lymphocytic leukemia (ALL) and acute myeloid leukemia (AML) are both hematological malignancies characterized by rapid onset. While AML is more common than ALL, both typically receive cytotoxic chemotherapy in first line. Upon complete remission, patients will be considered for allogeneic hematopoietic stem cell transplant (HSCT). The economic burden of malignant blood disorders was recently studied in Europe, with an estimated €3.6 billion in productivity losses. The objective of this review is to evaluate the impact on productivity and understand the societal burden of HSCT in ALL and AML patients. Methods: A rapid review was conducted to identify real-world evidence reporting work and productivity loss associated with ALL and AML, including the impact of HSCT. A search of PubMed was executed for citations published between April 1, 2014 to April 1, 2019 and limited to English language. Eligible studies examined outcomes on work productivity in patients diagnosed with ALL, AML, or combined hematological malignancies, with no geographical restriction. A single reviewer screened all identified citations and extracted key data from included papers. Results: A total of 13 unique real-world data studies were identified. Seven studies examined the impact of hematological cancers (including ALL and AML) with varied return-to-work outcomes reported. Of these, 3 studies observed positive return-to-work outcomes over time, while 4 reported decreased employment among patients when compared to the general population, although 2 of the 4 studies were focused on childhood hematological cancer survivors. A total of 6 studies examined the impact of HSCT on work productivity. Two studies reported opposing results in unemployment in adult survivors of childhood hematological cancers who received HSCT. The remaining 4 studies found a general decrease in employment or increase in low-income status among adult patients when comparing pre-HSCT to post-HSCT; however, 2 of these studies reported most patients were still employed post-HSCT, with 62% returning to work over 1 year post-HSCT and 77% of patients returning to work 5 years post-HSCT. Overall, there was a trend towards work reintroduction as an important outcome post-HSCT. Further, recurring themes included structural changes in the current delivery of health services or potential interventions to help rehabilitation post-transplantation and optimize employment. Conclusions: Work productivity outcomes are important facets of long-term survivorship care in patients with hematological cancers. Although there was a limited number of studies identified, results from the current rapid review indicate that while productivity is lower in patients with AML or ALL, including those treated with HSCT, a substantial proportion of patients are still actively employed. Future research should be directed toward understanding the causes of unemployment post-HSCT to help prevent adverse financial outcomes following this life-saving procedure. In terms of limitations, none of the identified studies compared work productivity outcomes of those who received HSCT to those who did not receive HSCT, among patients with hematological cancer. Four of the studies only examined patients pre- and post-HSCT and the remaining 2 studies compared patients to the general population; thus, the effect of HSCT could not be discerned from the effect of the disease. While HSCT is a costly and resource-intensive procedure, it remains the only potentially curative intervention for most hematological cancers. Advances in HSCT have dramatically improved clinical outcomes in cancer patients; resulting in lowered HSCT-related morbidity and mortality. Future studies with direct comparisons of patients with hematological cancer who received HSCT to those who did not receive HSCT would be desirable to estimate the indirect costs of impact of work productivity in these patients; however, ability to receive HSCT may remain confounded by variables that are challenging to measure, such as disease state, donor availability, HSCT reimbursement policies, and patient preference. Disclosures Scory: Medlior Health Outcomes Research: Employment. Shaw:Medlior Health Outcomes Research: Employment. Cowling:Medlior Health Outcomes Research: Employment. Peloquin:Pfizer Inc: Employment, Equity Ownership. Welch:Pfizer Inc: Employment, Equity Ownership. Charaan:Pfizer Inc: Employment, Equity Ownership. Brown:Pfizer: Employment, Equity Ownership.

Effect of early-stage Alzheimer's disease on household financial outcomes.

Significant limitations and rapid declines in financial capacity are a hallmark of patients with early-stage Alzheimer's disease (AD). We use linked Health and Retirement Study and Medicare claims data spanning 1992-2014 to examine the effect of early-stage AD, from the start of first symptoms to diagnosis, on household financial outcomes. We estimate household fixed-effects models and examine continuous measures of liquid assets and net wealth, as well as dichotomous indicators for a large change in either outcome. We find robust evidence that early-stage AD places households at significant risk for large adverse changes in liquid assets. Further, we find some, but more limited, evidence that early-stage AD reduces net wealth. Our findings are consequential because financial vulnerability during the disease's early-stage impacts the ability of afflicted individuals and their families to pay for care in the disease's later stage. Additionally, the findings speak to the value that earlier diagnosis may provide by helping avert adverse financial outcomes that occur before the disease is currently diagnosable with available tools. These results also point to a potentially important role for financial institutions in helping reduce exposure of vulnerable elderly to poor outcomes.

218-LB: Hypoglycemia Burden in T2D Patients: Rationale, Methodology, and Comparative Results of a Multisetting Nationwide Study Series

Introduction: Hypoglycemia places a significant burden, accounting for adverse clinical and financial outcomes. Objective: Integrated approach to determine burden of hypoglycemia in T2D patients in Portugal, accessed in an Outpatient Setting (pharmacies), Emergency Rooms (ERs) and Hospital Wards, contributing for a full country perspective of complementary settings. Methods: A series of 3 HypoglycemIa in POrtugal Studies (HIPOS) were developed: HIPOS-PHARMA, HIPOS-ER and HIPOS-WARD. They were observational, cross-sectional, multicentric studies designed to evaluate adult T2D patients treated with AHA attending pharmacies and reporting hypoglycemic events (PHARMA), admitted in ERs or hospitalized (WARD) for hypoglycemia. These studies were implemented over a period of non-consecutive 35 months (Jan13-Aug18) and with a national coverage. Results: Mild to moderate hypoglycemia in the 3 months prior recruitment were reported by 17.8% of the 1890 individuals enrolled by 233 pharmacies during HIPOS-PHARMA and were more likely in patients taking insulin and/or secretagogues. Only 46% of patients reported the episode to a HCP. Severe hypoglycemia accounted for 0.074% (n=238) of the 425,706 ER admissions in the 7 HIPOS-ER hospitals and occurred mainly on insulin- (55.0%) and secretagogue-based therapy (31.5%). When these patients needed hospitalization (44%), the mean total cost per hypoglycemic event was € 3,163 (€ 230 - € 26,818). As for HIPOS-WARD, 152 individuals were enrolled in 18 centers, 40.4% had previous hypoglycemia (last 12 months), and were also on insulin (42.1%) or secretagogues (34.9%). Conclusion: This study series allowed for the first time a nationwide multi-setting perspective of hypoglycemia in T2D patients, signaling that this event still represents a relevant burden in Portugal, despite significant improvements in hypoglycemia prevention strategies and the growing number AHA with low hypoglycemia risk. Disclosure S. Alão: Employee; Self; Merck Sharp &amp; Dohme Corp. L.C. Santos: Speaker’s Bureau; Self; Merck Sharp &amp; Dohme Corp. F. Araujo: None. J.M. Dores: Advisory Panel; Self; Merck Sharp &amp; Dohme Corp. J. Pelicano-Romano: Employee; Self; Merck &amp; Co., Inc. J.M. Conceicao: Employee; Self; Merck Sharp &amp; Dohme Corp. Stock/Shareholder; Self; Merck Sharp &amp; Dohme Corp. P. Mj: Employee; Self; Merck Sharp &amp; Dohme Corp.

Employment, Insurance, and Financial Experiences of Patients with Chronic Graft-versus-Host Disease in North America

Understanding the socioeconomic impact of chronic graft-versus-host disease (GVHD) on affected patients is essential to help improve their overall well-being. Using data from the Chronic GVHD Consortium, we describe the insurance, employment, and financial challenges faced by these patients and the factors associated with the ability to work/attend school and associated financial burdens. A 15-item cross-sectional questionnaire designed to measure financial concerns, income, employment, and insurance was completed by 190 patients (response rate, 68%; 10 centers) enrolled on a multicenter Chronic GVHD Consortium Response Measures Validation Study. Multivariable logistic regression models examined the factors associated with financial burden and ability to work/attend school. The median age of respondents was 56years, and 87% of the patients were white. A higher proportion of nonrespondents had lower income before hematopoietic cell transplantation and less than a college degree. All but 1 patient had insurance, 34% had faced delayed/denied insurance coverage for chronic GVHD treatments, and 66% reported a financial burden. Patients with a financial burden had greater depression/anxiety and difficulty sleeping. Nonwhite race, lower mental functioning, and lower activity score were associated with a greater likelihood of financial burden. Younger age, early risk disease, and higher mental functioning were associated with a greater likelihood of being able to work/attend school. In this multicenter cohort of patients with chronic GVHD, significant negative effects on finances were observed even with health insurance coverage. Future research should investigate potential interventions to provide optimal and affordable care to at-risk patients and prevent long-term adverse financial outcomes in this vulnerable group.

Policy Recommendations to Address Financial Toxicity Following Cancer in Low- and Middle-Income Countries: One Size Does Not Fit All

Background: Evidence to guide cancer policy-making is scarce in low- and middle-income countries (LMIC). Furthermore, most economic studies in cancer have been conducted from the provider's or payer's perspective. Aim: The ASEAN Costs in Oncology Study (ACTION) was conducted to provide the essential intelligence for national policymakers and official development assistance donors to construct economically sound national cancer control plans. Methods: In the ACTION study, 9513 newly diagnosed cancer patients from eight LMIC in southeast Asia were prospectively followed-up for adverse economic outcomes up to one year after diagnosis, through serial interviews and use of cost diaries. Results: Country-specific analysis of the ACTION Study data had revealed that just within a year of diagnosis, 1 in 2 Malaysian cancer survivors had reported spending more than 30% of their annual household income for cancer related expenditures (FC: financial catastrophe). Strikingly, Malaysia, albeit being a higher income nation, appeared to have fared worse than Thailand, where only 1 in 3 cancer survivors reported FC. Nonetheless, in contrast to finding of the regional study that medical payments (drugs, hospitalization, consultation), largely explained the incidence of FC following cancer, only half of the reported catastrophic expenditures in Malaysia were attributed to medical expenditures suggesting that nonmedical payments related to cancer (e.g., travel, accommodation, childcare) was an important contributor to adverse financial outcomes. Furthermore, marked institutional variations in levels of catastrophic expenditures were observed in Malaysia, even within the public healthcare system. Proportion of patients experiencing FC in the general government hospitals was only 33% compared with 65% in the public academic hospitals. Although late stage at cancer diagnosis largely explained the increased risk of adverse economic outcomes and death, patients from low-income households remained vulnerable even when diagnosed with earlier stages. Conclusion: The findings of the ACTION Study importantly highlight the need for LMIC to undertake their own studies examining the financial impact of cancer in the population, to take affirmative actions to reduce financial loss and premature deaths associated with cancer. From the Malaysian perspective, there appears to be an urgent need to improve social support for cancer in the country, be it through government-led programs such as disability insurance and short term credit or multisectoral collaboration with civil societies, private industries, and philanthropic organizations. Key policy changes should also include prioritization of programs which would allow early detection of cancer, re-examination of the national health financing system to ensure that public funds are channeled to those who need them the most, and addressing disparities in funding between public hospitals.

Unmet Need and Financial Impact Disparities for US Children with ADHD

ObjectiveThe 5.1 million US children with attention-deficit/hyperactivity disorder (ADHD) have pronounced needs in education, occupational and speech therapy, and medical and behavioral treatments. Given known associations of ADHD diagnosis with race/ethnicity and parent education, this study aimed to assess how measures of socioeconomic status correlate with both adverse family financial impact of ADHD and disparities in unmet treatment need for ADHD. MethodsSecondary analysis of children ages 8 to 17 years whose households participated in the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome. Using bivariate testing, we examined associations among measures of socioeconomic status with unmet ADHD treatment need and family financial impact. Logistic regression models estimated the odds of having unmet treatment need, adjusting for demographic factors and family financial impact. ResultsAmong US school-aged children with a current ADHD diagnosis, 44.3% experienced an adverse family financial impact from ADHD, and 11.6% had unmet need for ADHD treatment. Children with younger age at first ADHD diagnosis were more likely to experience adverse family financial impact. Children from non-English-speaking households were less likely to report unmet need compared to those from primarily English-speaking households. The adjusted odds of unmet need were twice as great among those who reported adverse family financial impact. ConclusionDeeper understanding of the influence of the household language is important in ADHD needs assessments. Considering overall family financial circumstances may also be pertinent, particularly as children age, because earlier diagnosis was associated with adverse financial outcomes. These findings could shape future clinic policies for targeting community resources.