Out Of Pocket Costs Research Articles

Area-level socioeconomic status impacts healthcare visit frequency by Australian inflammatory arthritis patients: results from the Australian Rheumatology Association Database.

Individuals with inflammatory arthritis (IA) require long-term rheumatologist care for optimal outcomes. We sought to determine if socioeconomic status (SES) influences general practitioner (GP) and specialist physician visit frequency and out of pocket (OOP) visit costs. We linked data from Australian Rheumatology Association Database (ARAD) participants with rheumatoid arthritis or psoriatic arthritis to the Pharmaceutical Benefits (PBS) and Medicare Benefits Schedule (MBS) from 2011-2018. Small-area SES was approximated as quintiles of the Index of Relative Socieconomic Advantage and Disadvantage. A comorbidity index (Rx-Risk) was determined from PBS data. Analysis was performed using panel regression methods. We included 1916 ARAD participants (76.3% rheumatoid arthritis, 71.1% women, mean [SD] age 54 [12] years and disease duration 6 [4] years). Participants averaged 9.0 (95% CI 8.6, 9.4) annual GP visits and 3.9 (3.8 to 4.1) annual specialist physician visits. After adjustment for sex, age, education, remoteness and comorbidity, there was an inverse relationship between annual GP visit frequency and higher SES quintile (-0.6 [-0.9, -0.3] visits/quintile) and a direct relationship between more frequent specialist visits and higher SES (linear slope 0.3 [0.2, 0.5] visits/quintile). Average OOP costs/visit were higher for specialist physician (AUD$38.43 [37.34, 39.53] versus GP visits (AUD$7.86 [7.42, 8.31], and higher SES was associated with greater OOP cost. Higher SES patients have relatively fewer GP visits and more specialist physician visits compared with lower SES patients, suggesting lower SES patients may receive suboptimal specialist physician care. OOP costs may be a contributing factor.

Abstract B144: Conceptual framework on health behaviors and experiences of Sub-Saharan African immigrant prostate cancer survivors

Abstract Background: Sub-Saharan African immigrants (SSAI) in the United States (US) constitute one of the fastest-growing segments of the immigrant population. Between 2010 and 2018, the SSAI population in the US increased by 53%, significantly outpacing the 12% growth rate for the overall foreign-born population in the US during that period. We define SSAI as the 2 million individuals living in the US originally from the region of the African continent located south of the Saharan desert. Despite their growing numbers, little is published about the extent to which SSAI adapt to health behaviors more common in the US or remain immersed in the values, beliefs, and practices reflective of their country of origin. Importantly, no study has comprehensively examined the social determinants of health factors among this population and its influence on health-seeking behaviors and decision-making regarding prostate cancer care and treatment. Aim: This study seeks to better understand the lived experiences, unmet needs and the impact of migration on the quality of life of SSAI cancer survivors in the US. Methods. We employ a qualitative approach guided by grounded theory. Selective sampling was used to identify potential participants from a database obtained via the Florida and Minesota cancer registries. We proceeded to conduct in-depth interviews with 16 cancer survivors recruited from the two caner registries. Results. We developed a conceptual framework illuminating the full range of social, behavioral, environmental, and structural factors associated with the experiences of SSAI prostate cancer survivors. From the data, the post diagnosis experiences of study participants can be categorized into three domains: 1) health behaviors; 2) treatment decision and antecedents; 3) challenges of being an immigrant. Characteristics of health behaviors include using informal care teams for social support and second opinions before treatment. Selective disclosure of diagnosis, changes to diet, exercise and searching for information about the diseases were other manifestation of behavior. While some participants made decisions about treatment soon after diagnosis, others took a more deliberative approach and relied on faith and family for social support. Some challenges in terms of being an immigrant include knowledge gaps about the US health system, lack of health insurance and transportation to hospital during treatment. Implication for public health practice. Some of the unmet needs of study participants include transportation cost to and from hospital for radiotherapy and other treatment and reducing the high out of pocket cost for co-payment and drugs. The knowledge deficit about navigating the US health system can be addressed through community-based intervention in partnerships with immigrant groups, advocacy organizations and faith-based organizations. The focus of this intervention should be to educate and empower SSAI men on how to navigate the US health system and be more assertive about their health needs and desires for treatment during doctor’s visit. Citation Format: Ernie Kaninjing, Gladys Asiedu, Kaitlin Van Voorhis, Daniel Lee, Rakinya Hinson, Mary Ellen Young. Conceptual framework on health behaviors and experiences of Sub-Saharan African immigrant prostate cancer survivors [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B144.

Abstract PS04-08: Sociodemographic Risk Factors and Prediction of Aromatase Inhibitor Non-Adherence in Women with Breast Cancer Enrolled in SWOG S1105

Abstract Background: Non-adherence to aromatase inhibitors (AIs) for breast cancer is common and increases risk of recurrence. Few prospective studies have systematically evaluated non-adherence and non-clinical factors associated with it. We analyzed baseline sociodemographic characteristics and financial factors associated with non-adherence to create a baseline composite risk-score for AI non-adherence. Methods: Patients enrolled in S1105 were required to have been on an AI for ≥30 days at enrollment. Patients were assessed for non-adherence of AIs every 3 months for 36 months, with non-adherence defined as urine AI metabolite assay results satisfying any of the following: < 10 ng/mL, undetectable, specimen submitted outside of the ± 21-day follow-up appointment window, or no submitted specimen. Factors included race, Hispanic ethnicity, age, education, income, health insurance type, and prescription cost. We also included socioeconomic deprivation and rural or urban residence using trial participants’ residential zip codes linked to the Area Deprivation Index (ADI) and Rural Urban Continuum codes (RUCC) respectively. For numeric factors and categorical factors with more than two levels, we used cutpoint analysis to determine the highest risk range by optimizing the Chi-squared statistic. For each resulting binary factor, we performed a logistic regression, adjusting for the study stratification factors and stratifying by treatment arm. Factors associated with adherence at the alpha=0.10 level were combined into a composite risk score, with study participants given one point for each baseline adverse risk factor. Secondarily, we examined a composite risk score including all factors, regardless of statistical significance. Results: In total, 724 patients were registered from 40 institutions between May 2012 and September 2013. The median age was 60.9 years, and 64.5% were on AI < 12 months prior to registration. Only 8% had out of pocket (OOP) cost >$30. Observed adherence at 36 months was 35.9%. Patients living in metro areas with populations ≥ 250,000 (RUCC ≤ 3) were more likely to be non-adherent (37.5% vs 28.3%, OR=1.50, p=.08); as were those who were younger, those without a college education, and those with limited (≤$5) OOP cost. ADI, race and ethnicity were not associated with non-adherence. The composite risk score was strongly associated with 36-month adherence. For each 1 unit increase in risk level, the risk of non-adherence increased 47% (OR=1.47, p< .001); the risk increased 64% for those with >2 vs. ≤2 risk factors (OR=1.64, p=.002). Results using all factors regardless of statistical significance were consistent. Conclusions: A composite model comprised of sociodemographic risk factors can identify patients on AI’s at much greater risk of long-term AI non-adherence. In addition to mitigating side effects, targeted interventions to improve adherence should focus on structural barriers among those at highest risk. Non-adherence (+/- 6 months) = factor + AI duration + AI type, stratified by arm Citation Format: Dawn Hershman, Anna Moseley, Kathryn Arnold, Julie Gralow, Alfred Neugut, Scott Ramsey, N. Lynn Henry, Joseph Unger. Sociodemographic Risk Factors and Prediction of Aromatase Inhibitor Non-Adherence in Women with Breast Cancer Enrolled in SWOG S1105 [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS04-08.

Association of household net worth with healthcare costs after radical cystectomy using real-world data.

Financial toxicity of bladder cancer care may influence how patients utilize healthcare resources, from emergency department (ED) encounters to office visits. We aim to examine whether greater household net worth (HHNW) confers differential access to healthcare resources after radical cystectomy (RC). This population-based cohort study examined the association between HHNW and healthcare utilization costs in the 90 days post-RC in commercially insured patients with bladder cancer. Costs accrued from the index hospitalization to 90 days after including health plan costs (HPC) and out-of-pocket costs (OPC). Multivariable logistic regression models were generated by encounter (acute inpatient, ED, outpatient, and office visit). A total of 141,903 patients were identified with HHNW categories near evenly distributed. Acute inpatient encounters incurred the greatest HPC and OPC. Office visits conferred the lowest HPC while ED visits had the lowest OPC. Black patients harbored increased odds of an acute inpatient encounter (OR 1.22, 95% CI 1.16-1.29) and ED encounter (OR 1.20, 95% CI 1.14-1.27) while Asian (OR 0.76, 95% CI 0.69-0.85) and Hispanic (OR 0.74, 95% CI 0.69-0.78, p < 0.001) patients had lower odds of an outpatient encounter, compared to White counterpart. Increasing HHNW was associated with decreasing odds of acute inpatient or ED encounters and greater odds of office visits. Lower HHNW conferred greater risk of costly inpatient encounters while greater HHNW had greater odds of less costly office visits, illustrating how financial flexibility fosters differences in healthcare utilization and lower costs. HHNW may serve as a proxy for financial flexibility and risk of financial hardship than income alone.

Feasibility and Implementation of an out-of-Pocket Cost Calculator for Pre-Treatment Financial Counselling in Cancer Patients

Introduction Public healthcare in Singapore is funded by a combination of subsidies, insurance, which includes national basic coverage (MediShield, MSL) and optional private coverage, pensions (MediSave, MSV) and out of pocket (OOP) costs. In Sep 2022, spiraling cancer costs led to a shift in national policy with the introduction of a Cancer Drug List (CDL) of cost-effective treatments. OOP costs are now determined by multiple factors such as subsidy status, financial resources, insurance claim limits, residency status, drug subsidy tier, therapeutic indication, dose and cost. To simplify this complex manual process, we developed ChemoCalc, a digital calculator for individualized OOP estimates. We hypothesize that it will increase OOP cost estimate accuracy, improve efficiency and have high uptake. Methods The study was performed in a Singapore tertiary cancer center. ChemoCalc was developed with a multi-disciplinary team comprising physicians, pharmacists, operations administrators, patient service associates and medical social workers. Data sources were consolidated and hierarchical logic determined for calculating regimen and patient-specific OOP cost. Data sources included the CDL, hospital formulary, chemotherapy protocols, chemotherapy facility fees and various national subsidy schemes. These were encoded into an algorithm by a third-party developer. The user interface and experience (UI/UX) was envisioned by the team with iterations based on feasibility testing. FCs were trained on using ChemoCalc and data was collected pre and post-ChemoCalc implementation. Feasibility outcomes were demand, acceptability, practicality and integration (the extent to which ChemoCalc could be deployed in a secure hospital IT environment). These were assessed through employee focus groups (FG). Reporting officers were not present during the FG. Implementation outcomes were adoption (percentage of eligible users using ChemoCalc for FC), engagement (percentage of returning users), efficiency (median time taken to perform FC) and accuracy (percentage of bills which are within ±10% of the FC estimate). For accuracy, 10 bills were randomly selected each month and compared against the pre-treatment FC. Results Prior to the development of ChemoCalc, the demand for automated FC was identified through employee engagement. ChemoCalc (Figure 1) was developed and iterated from Aug - Sep 2022. Feasibility assessment identified that simplicity underscored a good UI/UX. To reduce UI clutter and improve ease-of-use, an algorithm was encoded to ensure that only variables relevant to a particular regimen need to be entered (Figure 2). All data fields were accessible via the hospital electronic medical record. The final version of ChemoCalc was deemed acceptable and practical by FG. It was integrated into the hospital environment seamlessly and accessible from all hospital computers and personal mobile devices. Data collection for implementation outcomes took place from 1 Oct 2022 to 31 Mar 2023. ChemoCalc was used by 72 different members of staff from all job groups. On average, the prices of 2,484 regimens (mean 11 regimens per patient) were generated each month, with a total of 17,385 price estimates generated. 91% of price estimates were for subsidized patients and 9% for private patients. For staff performing FC, the adoption and engagement rate was 100%. ChemoCalc improved efficiency for the FC process with an accuracy of 95% (baseline 35%, 270% increase). Time spent computing OOP reduced from a median of 8 min (range 4.5 - 13) to 44 seconds (range 15 - 20) for simple regimens, and 23 min (range 15.5 - 44) to 1 min (range 0.3 - 1.3) for complex regimens respectively. Due to the convenience and simplicity, there was 100% uptake for pre-treatment FC, as staff have been able to process more FC requests and spend more time addressing patients' financial concerns. It has also allowed patients to compare costs of different treatment regimens. Conclusion The implementation of ChemoCalc was successful with 100% adoption rate and significantly improved efficiency and accuracy. ChemoCalc's algorithm can easily be adjusted to accommodate country- or institution-specific reimbursements for implementation elsewhere. Further studies are required to investigate if pre-treatment FC addresses financial toxicity or influences healthcare costs.

1609. Engagement in Care, Awareness, and Interest in Long-Acting Injectable Anti-Retroviral Therapy

Abstract Background Long Acting Injectable (LAI) therapy to treat HIV is now a viable alternative to daily oral medications. The success of early roll-out of LAI to eligible patients requires a better understanding of patients’ awareness and interest in this novel therapy. Methods We administered an electronic survey to patients attending an urban HIV clinic in the US South (Duke University). Eligible participants were 18+ years old with a most recent HIV-1 viral load &amp;lt; 200 copies/ml, without any evidence of genotypic resistance to LAI components or chronic hepatitis B. Survey recipients were asked questions on their current treatment, their awareness and interest in LAI, and were asked to rate common benefits and concerns associated with LAI. After probing awareness of LAI, patients were provided further details on LAI for consideration for the rest of the survey. The survey also included the 3-item Brief Index of Engagement in HIV Care, a patient-reported measure of engagement in HIV care that has predicted future retention in care outcomes. Results Between January-April 2023, 480 patients were screened; 319 were found to be eligible, and 159 (50%) completed the survey. 73% were male; 44% Black, 7% Latinx; mean age was 49. The majority (119, 76%) were aware of injectable treatments, and 87 (56%) were interested in LAI. Among proposed benefits of injectables, ease of travel without pills, fewer medication interactions, and lack of daily pill-taking were most appealing. Among proposed concerns with injectables, out of pocket cost and insurance coverage of the new medicine were most worrisome. Black patients were more likely to be interested in LAI, and interested patients tended to be younger, single, and more recently diagnosed with HIV. Overall, patients surveyed were highly engaged in care (Mean 4.5/5, SD: 0.5)., but engagement was not predictive of awareness or interest in LAI. This table summarizes and compares the key patient characteristics between the patients who rated themselves interested or not interested in LAI Conclusion As we roll out LAI in real world settings, it will be helpful to characterize which patients are most interested in order to optimize uptake and benefit. Ease of travel without pills, not having to remember daily doses, and fewer medication interactions were the most appealing reasons, while concerns about both insurance coverage and out of pocket cost will need to be addressed. Disclosures Mehri McKellar, MD, Gilead Sciences, Inc: Grant/Research Support

Impact of medically integrated pharmacies on oral anticancer medication prescription abandonment.

66 Background: Due to the high cost of oral anticancer medications, financial toxicity may limit patient access to treatment. Abandonment occurs when a patient does not fill a prescription. Higher out of pocket costs have been associated with higher rates of prescription abandonment of treatment across cancers with national abandonment rates typically reported as 18%. An integrated patient assistance process within the care team as occurs in a medically integrated pharmacy is postulated to lower abandonment rates. We measured prescription abandonment rates in the Texas Oncology (TXO) medically integrated pharmacy (MIP). Methods: We reviewed prescription data from the electronic health record (EHR) and our pharmacy dispensing system, for all new oral anticancer medications prescribed from January 2022 to December 2022. Prescriptions that were sent electronically from the EHR but did not have a corresponding dispense in the pharmacy dispensing software were classified as having a barrier to fill. Among the prescriptions that had a barrier to fill, we randomly selected cases for further detailed review to identify cause of barrier. By reviewing the EHR, we also examined whether patients filled any alternate oral or injectable anticancer agent within 60 days due to a formulary block, patient choice or physician choice. Abandonment was defined when patients did not receive their treatment or appropriate alternative treatment within 60 days of the written prescription date. Results: 17,442 prescriptions for oral anticancer medications were prescribed by Texas Oncology physicians. Of those 8460 were filled by the TXO MIP without extensive barriers. 8982 of prescriptions were not filled at our TXO MIP and of those 2895 (32%) prescriptions were further reviewed to determine cause of barrier to fill. 1435 (49.5%) prescriptions had a pharmacy benefit manager (PBM) design that routed the prescription to an external pharmacy and out of the continuity of care of the MIP. 827 (29%) of patients experienced financial toxicity and received free drug assistance with the help of the MIP patient assistance team. 72 (1.3 %) of patients were started on an appropriate alternative therapy with input from the medically integrated care team. 15 patients did not start their oral anticancer treatment which resulted in an abandonment rate of less than 1%. Conclusions: National abandonment is reported as high as 18% largely due to high out of pocket costs. The Texas Oncology MIP has a dedicated patient assistance team. Within the MIP, although 29% of patients had a financial barrier to fill, the prescription abandonment rate was &lt;1%. Oral anticancer medications filled in the MIP led to decreased prescription abandonment due to the integrated patient assistance, pharmacy, and clinical teams. A medically integrated pharmacy should be the preferred approach for specialty cancer medications.

“Bad memories and a big debt—not a legacy I want to leave.” Patient perspectives on cancer treatment choices, cost of care, and legacy goals.

283 Background: Legacy—how one hopes to be remembered and how one impacts others after death—is an unexplored and important dimension of care decision-making for people facing serious illness. This study examined 1) how people with cancer facing serious illness conceive of legacy, 2) the types of treatment choices people make with legacy in mind and 3) if and how patients want to discuss their legacy goals with their care team. Methods: We conducted a scoping literature review to characterize the legacy construct and identify legacy-related treatment choices. We conducted semi-structured telephone interviews with cancer patients at an integrated health system who had received at least 1 palliative care consult in the past year. Interview topics included patient definitions of legacy, the importance of legacy over time, and what mattered most as they made treatment choices. We used Atlas.ti to thematically analyze interview transcripts. Results: In the scoping review, we identified three major intersecting legacy goals that influence patients’ care choices: being remembered as an individual, being remembered for one’s social role, and impacting others' well-being. Financial legacy—the material artifacts related to one’s estate—cut across all three legacy domains and emerged as a substantial factor at the intersection of care decision-making and legacy planning. In qualitative interviews, many people worried that the cost of care and necessary medications would negatively impact the legacy they were able to leave behind. Examples included choosing less expensive or forgoing treatment to preserve their financial legacy (e.g. not wanting to lose their house because of medical costs); feeling shame at experiencing financial hardship due to cancer care costs (“I don’t want to be remembered begging people for gas money to get to my appointments”); and death planning with cost in mind (“I don’t want to leave a horrible mess behind.”). Few people had discussed their legacy goals with their health care team, but many wanted support to do so, especially as these goals were threatened by high out of pocket costs. Conclusions: People with cancer consider their legacy goals, and in particular their financial legacy, as they make treatment choices. Further work is needed to identify how and for whom legacy goals should be addressed as part of patient-centered care, including for whom legacy and financial legacy is most important.

Treatment adherence and clinical outcomes of osimertinib (Osi) among ethnic-minority patients (pts) with EGFR-mutated NSCLC.

e18536 Background: Osimertinib (Osi) is widely used in the management of patients with EGFR-mutated NSCLC but there is limited data on the treatment adherence and clinical outcome of Osi in ethnic minorities. This study aims to evaluate race/ethnicity, adherence and other demographic, socioeconomic and clinical factors of patients with NSCLC treated with Osi. Methods: A retrospective cohort study of a total of 102 patients with EGFR mutated NSCLC that were prescribed Osi from 1/1/16-12/31/22 with 46 patients within Montefiore’s own specialty pharmacy system with updated claims data. Adherence was measured using two methods with medication possession ratio (MPR) and proportion of days covered (PDC). Primary endpoint was overall survival (OS) along with secondary endpoints of progression-free survival (PFS) and treatment duration from the start of Osi, compared minority vs non-minority using log-rank testing and survival analysis with cox proportional models. Results: A median follow-up time of 10.5 months (mons), median age of 69 years old and 34.8% self-reported as Non-Hispanic Black (NHB), 45.6% as Hispanic (H), 10.9% as non-Hispanic White (NHW) and 8.7% non-Hispanic Asian. Treatment adherence did not differ between Blacks vs non-Blacks or Hispanics vs non-Hispanics using both MPR or PDC. The median out of pocket cost for our pts after financial assistance and insurance was around $80 (USD). Compared to non-Hispanics, Hispanics had similar OS, PFS and treatment duration. However, compared with Non-Blacks, Blacks had inferior PFS (p=0.021) and borderline significance of worse OS (p=0.052) and shorter duration of Osi (p=0.068). Further results are summarized in the table. Conclusions: Our study demonstrates that treatment adherence did not differ among minority vs. non-minority patients. However, unlike Hispanics who had similar survival to non-Hispanics, Blacks had inferior PFS, OS and shorter duration of Osi compared to Non-Blacks. This warrants further research on the underlying mechanisms to help improve patient care and outcome while undergoing Osi treatment especially in Black pts. [Table: see text]

Profile of toxicities and quality of life in long-term survivors treated with immunotherapy: A prospective cross sectional trial.

6569 Background: Long-term cancer survivors (LTS) patients (pts) treated with immunotherapy (IT) represent a relatively new population whose characteristics, such as long-term toxicities, quality of life (QoL), and financial toxicities, need to be elucidated in a real-world setting. The aim of this study is to evaluate long-term toxicities in patients free of disease progression and treated with IT. Methods: This is a cross-sectional, multicentric study, involving ten Italian centres. Pts should have started IT (as monotherapy or combination, either in curative or adjuvant setting) more than 2 years before accrual and they needed to be progression free at last follow up (fup). Subjects who discontinued IT for disease progression or who started any subsequent line of systemic treatment were excluded. We retrieved baseline demographic and clinical characteristics of the pts, as well as haematological and biochemical exams at the start of IT (baseline) and at the last fup. We also assessed the patient's toxicities (according to CTCAE v5.0) at last fup and we submitted to each patient three questionnaires: PRO-CTCAE (selection of questions), EORTC QLQ C30, and FITALY (for financial toxicities), which were analysed according to subdomains. Results: We enrolled 141 LTS pts treated with IT from 2013 to 2022. Median age was 69 years (35-88), most were male (72%), and still receiving IT at time of last fup (72%). Primary tumour was in lung (43%), genito-urinary tract (26%), or melanoma (14%). IT included pembrolizumab and nivolumab in 40% and 32% of cases, respectively. The median global health status of QoL was 83 (IQR 25). Any toxicities &gt; G2 negatively impacted on individual functional scales (physical, p=0.02; role, p= 0.06; and social p=0.08). A higher baseline Charlson Comorbidity Index was associated with worse global health status (p=0.02) at last fup. Most frequent low grade adverse events were fatigue, dyspnoea, and insomnia; younger age (&lt; 65 years) was associated with higher pain (p=0.04). PRO-CTCAE questionnaires showed that the prevalent complained symptoms were rheumatological and cutaneous, regardless of tumor site. The most affected domain of financial toxicities was financial stress, including costs for out of pocket medications and transports. Pts with melanoma (p=0.01), with skin toxicities (p=0.04), and younger than 65 years (p=0.01) were at higher risk of financial toxicities (global score). Conclusions: Overall QoL is well preserved in LTS treated with IT. At long term fup, the pts complained mostly about rheumatological and skin adverse events. Financial stress due to out of pocket costs was the most affected financial toxicity domain. Baseline comorbidities predicted a worse long-term global health status, while young age, skin toxicities and melanoma predicted higher financial toxicities.

Financial toxicity and quality of life among people with chronic myeloid leukemia on tyrosine kinase inhibitors.

e18918 Background: Costs associated with treatment of Chronic Myeloid Leukemia (CML), along with out of pocket (OOP) expenses related to cancer care, put CML patients at risk for financial toxicity (FT). Although FT is considered a side effect of many cancer treatments, little is known about how FT affects quality of life among CML patients treated with Tyrosine Kinase Inhibitors (TKIs). In this study, we examined the association between FT, demographic factors, and health related quality of life (HRQOL). Methods: A secondary analysis was conducted using data from a parent study examining adherence trajectories in people with CML treated with TKIs. Descriptive, bivariate, and multivariate analyses were used to describe the sample, assess demographic and disease-specific FT correlates, and assess the predictive value of FT on HRQOL. FT was assessed by the Comprehensive Score for Financial Toxicity (COST Facit V2; higher scores were better) along with the Medical Expenditure Panel Survey (MEPS). HRQOL was assessed using the EuroQol 5-Dimension (EQ-5D-5L) single summary index score. Results: Of the 118 participant sample, about half were male (52%), White (57%), married (53%), and currently employed (59%) with a mean age of 49. Most had some college credit (76%). Many reported making financial sacrifices because of cancer costs (42% reduced spending on vacation/leisure activities, 31% delayed large purchases, 24% reduced spending on basics like food and clothing, and 27% used savings set aside for other purposes). Most (62%) reported ever being worried about having to pay large medical bills related to their cancer and 15% reported borrowing money or going into debt to cover cancer care costs. About half (51%) reported never discussing OOP costs for cancer care with their doctor. Overall, participants reported low FT (mean = 25, standard deviation = 11), but approximately 26% of respondents noted FT levels associated with significant financial burden (COST &lt; 17.5). In bivariate analyses, greater FT was associated with Black race, not married/partnered status, unemployed, high school education or less, and lower income. FT was not significantly associated with gender or age. In multivariable models, FT was significantly associated with HRQOL index (β = 0.011, SE = 0.002, P &lt; 0.001) after adjusting for individual characteristics. Age (β = -.003, SE = 0.001, P = 0.01) and education (β = .125, SE = 0.05, P = 0.027) also seemed to be important correlates of HRQOL index. Conclusions: Financial concerns are a common worry for individuals receiving treatment for CML. The association between FT and HRQOL suggests a need for assessing and addressing FT as part of routine care of people with CML who are taking TKIs. Further work is needed to understand the longitudinal experience of FT of people with CML on continuous treatment to help identify individuals who are most in need of intervention across the treatment continuum.

PATIENT SATISFACTION WITH IN-OFFICE HAND PROCEDURES

In the field of hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the WALANT method. We seek to investigate the degree of patient satisfaction, out of pocket cost, convenience and comfort experienced with in-office hand procedures.A ten question survey consisting of a ten-point Likert scale of agreement and questions asking for a numerical answer was administered via phone call to 33 patients treated with minor hand operations in the office setting in the United States.There were 18 male and 15 female respondents with an average age of 65.59±12.64 years. Respondents underwent procedures including trigger finger release (18), needle aponeurotomy (7), and other minor hand operations. Survey responses indicated strong agreement with questions 1-3 and 6–8, with responses averaging 9.60±0.23 in these positive metrics. Questions 4 and 5, which asked whether the surgery and recovery period were painful, respectively, averaged 2.65±0.49, indicating a mild level of disagreement that either was “painful”. Additionally, most patients responded that they did not take time off work (12) or are not currently employed (11). Other respondents (3) reported taking between one to five days off work post-operatively. 27 respondents also reported an out of pocket cost averaging $382±$976, depending on insurance coverage.Patients reported a small degree of pain in the operative and post-operative period, a high degree of comfort and convenience and a high degree of satisfaction. Likewise, the patient-reported out of pocket cost was far lower than comparable surgical costs in alternate settings. These results support the use of in-office procedures for minor hand surgeries from a patient perspective and indicate a nearly universal intent to repeat any future hand operations in the office setting.

Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers

BackgroundMedication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited. ObjectiveTo describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering. Designand Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after “go-live” of the RTPB system(s) between 2019 and 2020. Main measuresImplementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates. Key resultsDifferences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after “go-live,” RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered. ConclusionsIn this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.

Association of individual-socioeconomic variation in quality-of-primary care with area-level service organisation: A multilevel analysis using linked data.

Ensuring equitable access to primary care (PC) contributes to reducing differences in health related to people's socioeconomic circumstances. However, there is limited data on system-level factors associated with equitable access to high-quality PC. We examine whether individual-level socioeconomic variation in general practitioner (GP) quality-of-care varies by area-level organisation ofPC services. Baseline data (2006-2009) from the Sax Institute's 45 and Up Study, involving 267,153 adults in New South Wales, Australia, were linked to Medicare Benefits Schedule claims and death data (to December 2012).Small area-level measures of PC service organisation were GPs per capita, bulk-billing (i.e., no copayment) rates, out-of-pocket costs (OPCs), rates of after-hours and chronic disease care planning/coordination services. Using multilevel logistic regression with cross-level interaction terms we quantified the relationship between area-level PC service characteristics and individual-level socioeconomic variation in need-adjusted quality-of-care (continuity-of-care, long-consultations, and care planning), separately by remoteness. In major cities, more bulk-billing and chronic disease services and fewer OPCs within areas were associated with an increased odds of continuity-of-care-more so among people of high- than low education (e.g., bulk-billing interaction with university vs. no school certificate 1.006 [1.000, 1.011]). While more bulk-billing, after-hours services and fewer OPCs were associated with long consultations and care planning across all education levels, in regional locations alone, more after-hours services were associated with larger increases in the odds of long consultations among people with low- than high education (0.970 [0.951, 0.989]). Area GP availability was not associated with outcomes. In major cities, PC initiatives at the local level, such as bulk-billing and after-hours access, were not associated with a relative benefit for low- compared withhigh-education individuals. In regional locations, policies supporting after-hours access may improve access to long consultations, more so for people with low- compared with high-education.

Abstract P6-05-55: Financial Toxicity Outcomes on a Phase I 5-fraction Partial Breast Irradiation Protocol for Early Stage Breast Cancer

Abstract Purpose/Objectives: Accelerated partial breast irradiation (APBI) has been shown to have both acceptable oncologic and cosmetic outcomes for early stage breast cancer following breast-conserving surgery (BCS). Given the demonstrated financial toxicity (FT) of conventional radiation treatments on breast cancer patients, we wanted to quantitatively assess the FT on patients treated with APBI in our phase I five fraction stereotactic APBI (S-PBI) trial, which could be generalized across APBI treatment regimens. Methods: A phase I dose escalation trial of S-PBI for early stage breast cancer following BCS was conducted. Women age &amp;gt; 18 years with in-situ or stage I-II (AJCC 7) invasive breast cancer &amp;lt; 3 cm following BCS with &amp;gt; 2 mm margins were treated with S-PBI in 5 fractions to a total dose of 30 to 40 Gy over 2.5 Gy increments (Clinical trials.gov ID NCT01162200). One month following completion of treatment, patients were asked to complete our novel “Patient Perspective Cost and Convenience of Care Questionnaire” developed at our institution. Results: Of 75 patients enrolled and treated, questionnaire data was available for 66 patients. Our trial encompassed a wide spectrum of annual household incomes, with 25.5% of patients (n=14/55) reporting income of less than $30k and 45.5% (n=25/55) reporting incomes of more than $80k. Educational status was also well represented with 53.1% completing at least some college (n= 34/64), 25% holding post graduate or professional degrees (n=16/64), and 21.9% patients reporting a high school equivalent or less (n=14/64). Overall 48.4% of patients (n=30/62) said that oncologic treatment did not present a financial burden; however, 29.0% (n=20/62) patients reported a somewhat to significant financial burden. Neither household income nor patient education status predicted perceived FT. Of the 6 patients (9.7%) who reported significant FT, 5 reported travelling at least 25 miles one way for treatment with 2 of these patient travelling over 175 miles. Half of the patients reported having private insurance for medication (49.2%, n=32/65), 33.8% had governmental coverage (n=22/65), 6.1% had both private and government coverage, 7.7% had no coverage (n=5/65), and 3.0% were unsure of their coverage (n=2/65). Only 1 of the 6 patients with significant FT had no coverage. Over half of the patients (54.2%, n=34/62) reported a co-pay during their treatment with a median out of pocket cost of $300 for treatment (range $10-10000, n=16). Over half of the patients were working full or part time during treatment (54.2%, n=32/59). All 26 patients that were working full time had to take time off work for treatment (median of 5 days, range 0.25 days – 10 days). Over a third of these patients (34.6%, n=9) had to use vacation time or unpaid time off. There was an additional patient who reported months off without pay. Additionally, 24.2% of patients (n=15/62) reported they had family or friends take time off work due to the patient’s treatment. Finally, patients were surveyed on the treatment related disruption to their daily activities and enjoyment of life rated on a scale 0-10, with 0 being no disruption, median values were 3 and 1, respectively. Patients also reported a median score of 10 (scale 0-10, 10 being most satisfied) on satisfaction with treatment time. Conclusions: In this cohort of patients, interestingly FT was significant primarily in the 10% of patients who traveled a significant distance for these treatments. However, despite this, and the fact that patients were undergoing cytotoxic cancer therapy, impressively, all patients were uniformly satisfied with treatment time (median score of 10), and most did not express significant disruption to their life. We plan to explore the impact of further reducing treatment fractions (with our single fraction S-PBI studies) on FT and quality of life in future studies. Citation Format: Ambrosia Simmons, David Sher, Dong W. Nathan Kim, Marilyn Leitch, Rachel Wooldridge, Sally Goudreau, Stephen Seiler, Sarah Neufeld, Maggie Stein, Kevin Albuquerque, Ann Spangler, John Heinzerling, Dan Gardwoood, Stella Stevenson, Chul Ahn, Chuxiong Ding, Robert Timmerman, Asal Rahimi. Financial Toxicity Outcomes on a Phase I 5-fraction Partial Breast Irradiation Protocol for Early Stage Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-55.

Financial Toxicity: A Barrier to Achieving Health Equity in Cancer Care

Financial Toxicity: A Barrier to Achieving Health Equity in Cancer Care

Power-assisted Liposuction for Lymphedema: A Cost-utility Analysis.

Extremity volumes from all patients who underwent debulking surgery of the upper extremity at two institutions between December 2017 and January 2020 with at least 12 months follow-up were included. Procedural costs were calculated using Medicare reimbursement data. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years. A decision tree was generated, and incremental cost-utility ratios were calculated. Sensitivity analyses were performed to evaluate our findings. Debulking surgery is associated with a higher clinical effectiveness (quality-adjusted life year) of 27.05 compared to conservative management (23.34), with a relative cost reduction of $74,487. Rollback analysis favored debulking surgery as the cost-effective option compared to conservative management. The resulting negative incremental cost-utility ratio of -20,115.07 favored debulking surgery and indicated a dominant strategy. Our study supports the use of debulking surgery for the treatment of chronic lymphedema of the upper extremity.

A Mixed Methods Study to Examine the Influence of Structural Racism on Treatment in Acute Myeloid Leukemia

Background Multiple cancer registries including SEER and NCDB have repeatedly demonstrated increased mortality in non-white AML patients, with the survival disparity widening over the past 2 decades. A recent mediation analysis conducted in our newly created Chicago AML registry suggests that the Black-White and Hispanic-White survival disparity is significantly mediated by census tract variables (tract affluence, disadvantage and segregation) and these serve as surrogates for structural racism (Abraham et al. Blood 2022). In the current study we try to operationalize the mechanisms of structural racism contributing to disparities in myeloid malignancies Methods A prospective mixed-methods approach using quantitative (questionnaires) and qualitative (semi-structured interviews) methods is employed to uncover the complex interrelationship between individual, neighborhood/built environment and community level factors (Fig. 1A) that can influence treatment outcomes. Patients are enrolled 30-90 days from diagnosis and will be followed for two years. Validated questionnaires evaluate: patients' neighborhood and environmental living conditions (AHC HRSN), health literacy (CHLT-6), financial toxicity (COST-FACIT), medication affordability/adherence (ARMS), and mental health (PHQ-4). This is complemented by qualitative data from semi-structured interviews. The transcripts are processed and coded, using a qualitative data management software, and emerging themes noted (Fig. 1B). Results Data collection is ongoing and completed on 18 patients with aggressive hematologic malignancies, majority with AML and high risk MDS. The median age is 56 years with 50% self-declaring as NHW, the remainder NHB, Hispanic and Asian. Only 25% received a college education, 50% reported a median household income below $50,000, and the patient was the primary or sole financial provider for the family in one-half of cases. While most patients did not report struggles with insurance coverage and out of pocket costs on the questionnaire, they did express worry about long-term consequences such as job security and financial well-being. Financial toxicity was highest and health literacy lowest in the NHB patients. 62% reported access to internet and 50% had smartphones. Patients did not endorse concerns about housing or neighborhood conditions influencing their health care. Medication affordability/adherence was adequate across groups. Most patients felt sufficiently supported by family for transportation but 25% reported that they could use more help with ADLs. One-half of patients reported feeling loneliness and stress on the PHQ-4 questionnaire, and detailed the consequences of a long hospitalization (isolation, missing family events) in interviews. Adolescent and young adult (AYA) patients also discussed grappling with their newfound cancer identity. Notably, 25% of patients reported >5 alcoholic drinks /day for men or >4/day for women. Medical mistrust was not reported, most patients expressed trust/confidence in their treatment team which was improved by regular communication and responsiveness. Discussion The mixed methods approach offers an ample source of data from both questionnaires and interviews for a fuller understanding of factors that can influence inequity in the delivery of leukemia care. The unique perspectives of an understudied population at a minority serving cancer identified targetable barriers to care. There is broad need for additional assistance at home for ADLs, mental health concerns as well as significant levels of alcohol use which have not been previously explored. A third of patients lacked access to regular internet, an important source of education and communication that could widen health inequities. Patients expressed unique challenges specific to AML including the prolonged hospitalizations resulting isolation, and difficulty coping with the cancer identity reported by the AYA population. Regular communication with a responsive medical team contributed positively to patient-provider relationships. Ongoing work includes i) expanding the current cohort across a broader socioeconomic spectrum to further enrich the data ii) prospectively linking this data to treatment complications and outcomes. The results of this study can guide future strategies for targeting resources and interventions to narrow leukemia outcome disparities. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Effect of Out of Pocket Cost on Following Mammography Screening

Aim: To analyze the effect of out of pocket cost on subsequent mammography screening. Study design: Retrospective observational study Place and duration of study: Department of Radiology, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat from 1st April 2021 to 31st March 2022. Methodology: One hundred female patients having ages 40-65 years with health insurances were followed from their baseline mammography screening up to their 12-36 months screening was enrolled. The clinical recorded, adjusted clinical group and other related information were documents. Results: 69% supported by a low deductible health policy while 31% were supported with a high deductible health policy The Adjusted Clinical Group score showed 74% within 0.3 scoring. For baseline mammography a decreased by 3.4% up to 12-24 months time was noticed. Conclusion: Out pocket cost has a significant effect of decreasing patient’s number for subsequent mammography screening. Keywords: Breast carcinoma, Mammography, Screening

Household costs associated with seeking malaria treatment during pregnancy: evidence from Burkina Faso and The Gambia

BackgroundMalaria in pregnancy remains a major health threat in sub-Saharan Africa to both expectant mothers and their unborn children. To date, there have been very few studies focused on the out of pocket costs associated with seeking treatment for malaria during pregnancy.MethodsA cross-sectional survey was undertaken in Burkina Faso and The Gambia to estimate the direct and indirect costs associated with outpatient consultations (OP) and inpatient admissions (IP). Direct costs were broken down into medical (admission fees, drug charges, and laboratory fees), and non-medical (transportation and food). Indirect costs reflected time lost due to illness. In total, 220 pregnant women in Burkina Faso and 263 in The Gambia were interviewed about their treatment seeking decisions, expenditure, time use and financial support associated with each malaria episode.ResultsIn Burkina Faso 6.7% sought treatment elsewhere before their OP visits, and 27.1% before their IP visits. This compares to 1.3% for OP and 25.92% for IP in The Gambia. Once at the facility, the average direct costs (out of pocket) were 3.91US$ for an OP visit and 15.38US$ of an IP visit in Burkina Faso, and 0.80US$ for an OP visit and 9.19US$ for an IP visit in The Gambia. Inpatient direct costs were driven by drug costs (9.27US$) and transportation costs (2.72US$) in Burkina Faso and drug costs (3.44 US$) and food costs (3.44 US$) in The Gambia. Indirect costs of IP visits, valued as the opportunity cost of time lost due to the illness, were estimated at 11.85US$ in Burkina Faso and 4.07US$ in The Gambia. The difference across the two countries was mainly due to the longer time of hospitalization in Burkina Faso compared to The Gambia. In The Gambia, the vast majority of pregnant women reported receiving financial support from family members living abroad, most commonly siblings (65%).ConclusionsHigh malaria treatment costs are incurred by pregnant women in Burkina Faso and The Gambia. Beyond the medical costs of fees and drugs, costs in terms of transport, food and time are significant drivers. The role of remittances, particularly their effect on accessing health care, needs further investigation.