Out Of Pocket Costs Research Articles

Investigating consumer hospital choice: Demand and supply-side levers could address health care costs

ObjectivePolicies that aim to steer patients from higher to lower cost providers of comparable quality have potential to impact health care cost growth – but their effectiveness depends, in part, on consumer perceptions of value and willingness to make tradeoffs. We sought to understand what was required to shift substantial numbers of consumers to higher-value care settings for several “shoppable” conditions. MethodsA discrete choice experiment (DCE) was conducted to elicit patient preferences for hospital type. We used an Internet panel of 1005 Massachusetts residents to conduct this experiment in 2016. The DCE data were analyzed using alternative-specific conditional logit regression. ResultsConsumers reported large influences of out of pocket costs, physician referrals and quality ratings on their choice of hospital. For example, up to a third of consumers would shift from Academic Medical Centers to community hospitals if the latter had higher quality ratings, lower copays or a physician referral. Choice of site for maternity care was most influenced by physician referral; cancer treatment and orthopedic procedures by quality ratings; and MRI by cost, suggesting that patients prioritize quality over cost as perceived risk increases. Conclusions and implicationsOur findings provide guidance for identifying promising policy levers that most influence consumer choice of provider. However, the extent to which potential levers can influence choice is likely to be dependent upon the kind of care being sought.

Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing.

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

Patterns of Utilization and Outcome of Hematopoietic Stem Cell Transplantation Among Various Cancers: A Nationwide Analysis

Introduction: Hematopoietic stem cell transplantation (HSCT) or bone marrow transplantation (BMT) is performed to treat hematologic malignancies such as acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), multiple myeloma (MM), chronic lymphocytic leukemia (CLL), chronic myeloid leukemia (CML), myelodysplastic syndrome (MDS), lymphomas (HL and NHL) and hemophagocytic lymphohistiocytosis (HLH). Inpatient data on the characteristics of patients receiving BMT, the distribution of BMT among the above mentioned hematological cancers and their outcomes is lacking. This study analyzes patient and hospital characteristics of patients undergoing BMT, in addition the study describes resource utilization and outcomes of BMT among various hematological cancers.Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2014 Database (HCUP-NIS). Patients were included in the study if they had a procedure diagnosis of BMT and a medical diagnosis of acute or chronic leukemia (ALL, AML, CLL, CML), lymphoma (HL and NHL), MM, MDS or HLH. HSCT or BMT includes both Allogeneic and Autologous Stem Cell Transplant however we did not differentiate one from the other since BMT in MM is almost universally auto stem cell transplantation. We performed descriptive statistics to characterize the cohort in terms of personal demographic factors (age, race, sex, insurance type, community level income level), indication for HSCT, hospital characteristics (size, region, teaching status, and urban or rural location), and timing of admission (weekend or weekday). We performed univariate analyses using these variables to determine the associations with LOS and mortality. All analyses apply the HCUP-NIS weights.Results: The cohort comprised of 18,275 patients who underwent HSCT. Most patients were male (59.1%), white (70.4%), aged 51-70 years (53.9%), and covered by private insurance (57.0%). Nearly a third (31.3%) lived in communities with the highest quartile of household incomes. The most common diagnosis associated with HSCT was MM (27.6%), followed by AML (15.6%). Most HSCT was performed at large hospitals (74.5%); only 0.1% were performed in rural and 1.1% at non-teaching hospitals. Average length of stay (ALOS) was 25.54 days (95% CI 24.19 to 26.89) and the mean total charges (per hospitalization) were $346,555 (95% CI $310,465 to $382,645) and net charge was $6.33 billion. Several factors were associated with lower ALOS: age (AMD -0.31, 95% CI -0.37 to -0.24), Charlson index (AMD -0.85, 95% CI -1.60 to -0.12), private insurance coverage (AMD -3.65, 95% CI -5.25 to -2.067) and self pay status (AMD -13.56, 95%CI -17.13 to -10.00). Urban (AMD 6.74, 95% CI 1.01 to 12.48), and teaching hospitals (AMD 8.31 95% CI 2.88 to 13.72) had longer ALOS. Only Hispanic race (OR 0.23 95% CI 0.068 to 0.77) and Charlson index (OR 1.2 95% CI 1.04 to 1.39) were associated with mortality. Multivariate analysis did not show any significant associations of mortality with age, race, geographic region, hospital size, median household income, type of insurance, timing of admission, or teaching or location status of hospitals.Discussion: MM accounted for the most significant portion of HSCT in 2014, although its incidence is lower than that for leukemia and lymphoma. This may partly be because autologous stem cell transplantation (ASCT) after high dose chemotherapy is the mainstay of MM treatment. In contrast to other hematological malignancies, some MM patients may also undergo tandem transplantation. Most HSCT recipients were covered under private insurance, and a significant proportion of them came from communities with the highest quartile of median household incomes. This suggests that socioeconomic status influences access to HSCT therapy, likely related to out of pocket costs. In addition, social determinants of health including health literacy, access to health care may play a role. Surprisingly, ALOS decreased with increasing age and Charlson comorbidity index. Reasons are unclear but may be related to increased or earlier mortality. Additional studies could help to elucidate this relationship. DisclosuresBussel:Rigel: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Momenta: Consultancy; Uptodate: Honoraria; Protalex: Consultancy; Amgen Inc.: Consultancy, Research Funding; Prophylix: Consultancy, Research Funding. Marks:Odonate: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Equity Ownership; Lilly: Membership on an entity's Board of Directors or advisory committees; Heron: Membership on an entity's Board of Directors or advisory committees; UPMC: Employment.

Financial toxicity of cancer treatment at a diverse county hospital.

76 Background: The rising costs of cancer care increasingly results in financial distress for patients and their families. Low-income patients face a greater burden of financial toxicity, but few studies have characterized what factors contribute to this, and what interventions can relieve toxicity. Methods: From October 2017 to December 2017, we used a validated COST survey tool to understand the extent of financial burden that patients with cancer experience. We surveyed patients who receive their oncology care in a medical system that serves predominantly minority and low-income patients in Santa Clara County. We collected demographic information including sex, education level, ethnicity, income, insurance status, monthly out of pocket costs (OOPC) and employment status prior to diagnosis. We used a multivariable linear regression to study the association between the patient factors and financial burden as demonstrated by the COST score. All data were analyzed using Stata 14. Results: Demographic information is presented in Table 1. A total of 152 patients completed all 11 items of the COST survey. In the multivariate model, there was no significant difference in COST score by sex, education level, or ethnicity. However, income ≤$25,000 was associated with higher COST scores (p = 0.019), as was higher monthly OOPC (p = 0.003). Medicare patients and patients who were employed prior to diagnosis tended to have higher COST scores although not quite statistically significant (p = 0.057, p = 0.083). Conclusions: Patient-reported financial toxicity is an unmet concern among patients in this single institution study with a high proportion of underinsured patients. Higher OOPC and low income was associated with a higher financial burden. These findings suggest that patients would benefit from targeted interventions to mediate out of pocket costs of cancer care.[Table: see text]

MS17.02 Financial Toxicity and Out of Pocket Costs

Increasingly, patients are sharing the brunt of high cancer care costs, even when patients have insurance, due to increases in co-payments and high-deductible health plans. The out of pocket (OOP) costs borne by patients with cancer in the US was $4 billion in 2014. In an analysis between 2011-2014, the average per patient OOP costs in the first year after diagnosis were between $3,600 and $5,500 depending on the cancer type. The OOP costs were the highest on the month of diagnosis and declined subsequently but never reached the pre-diagnosis level. In countries without health insurance system, patients bear 100% of the drug costs OOP. This usually means that the patient and family must cut down on other daily living expenses or draw from savings and even sell their properties to compensate for the extra health care expenditures. Sometimes, it can mean treatment non-adherence, bankruptcy, or personal or familial stress. Such adverse outcomes due to economic impact of cancer treatment on patient and family are now collectively referred to as “financial toxicity” of cancer treatment. Financial toxicity refers to all the downstream detrimental effects on the survival, quality, and daily life activities of patients and their families as a result of excess financial strain caused by the diagnosis of cancer. In my presentation, I will discuss the causes and effects of financial toxicity in the context of lung cancer and propose some solutions. financial toxicity, cost of cancer drugs, out-of-pocket

PDB13 - Non-Severe Hypoglycemia Episodes (Nshes) Clinical And Economic Outcomes: A Comparison Between Sulfonylurea (Su) And Sodium-Glucose Co-Transporter 2 Inhibitor (Sglt2i) As Add On To Metformin From A Canadian Perspective

Non-severe hypoglycemia episodes (NSHEs) are associated with clinical adverse outcomes, a lower health-related quality of life, an increased burden of disease and reduced work productivity. The objective of this study was to estimate prevalence of NSHEs and associated economic outcomes attributable to SU versus SGLT-2 inhibitor initiation after metformin over one year for Canadian patients with type 2 diabetes (T2DM). Risk Difference for NSHEs was calculated for SU and SGLT2-I from RCTs data. Estimation of NSHEs attributable to SU utilization in Canada was calculated from published data. Both direct and indirect costs associated with NSHEs were obtained from previous published studies in literature. Number of patients with T2DM and exposure to SU in Canada in 2016 was estimated to be 1,246,438. The average underreported NSHEs in clinical settings was estimated at 67.7%. Risk Difference for NSHEs for SU versus SGLT2-I was estimated at 26.7%. Estimation of excess NSHEs attributable to SU utilization versus SGLT2-I in Canada was estimated at 130,434 events per year [sensitivity analysis: Minimum 80,680 and Maximum 624,465]. Total indirect costs including loss of work productivity and out of pocket costs secondary to excess NSHEs due to SU utilization versus SGLT2-I after metformin was estimated CDN$8.6M (M=millions) for 2016 [sensitivity analysis: Minimum CDN$5.3M and Maximum CDN$81.2M]. NSHEs, which is a forgotten variable in economic evaluations for healthcare reimbursement models, occur frequently in real world clinical settings but are infrequently reported. NSHEs can lead to a significant loss of work productivity and out of pocket costs.

The burden of out of pocket costs and medical debt faced by households with chronic health conditions in the United States.

IntroductionTo examine the relationship between chronic health conditions and out-of-pocket costs (OOPC) and medical debt.MethodsSecondary data from the 2013 Panel Study of Income Dynamics (PSID) was used. Households whose head of household and spouse (for married households) were 18 to 64 years old were included.ResultsHouseholds with 1 to 3 chronic conditions had higher odds of having any OOPC compared to households with no chronic conditions (AOR 1.74, 95% CI 1.39, 2.17) (p < .01). Households with 1 to 3 and 4 or more chronic health conditions were associated with higher odds of having any medical debt (AOR 2.24, 95% CI 1.75 to 2.87; AOR 5.04, 95% CI 3.04 to 8.34) compared to those with no chronic conditions (p < 0.01). Similarly, 1 to 3 and 4 or more chronic health conditions was associated with higher amounts of OOPC (Exponentiated Coefficient 1.18, 95% CI 1.03 to 1.36; Exponentiated Coefficient 1.56, 95% CI 1.17 to 2.07) and medical debt (Exponentiated Coefficient 1.69, 95% CI 1.23 to 2.34; Exponentiated Coefficient 2.73, 95% CI 1.19 to 6.25) compared to households with no chronic conditions (p < 0.05).ConclusionsFindings from this study show that the presence of chronic health conditions impose a large financial burden on some households.

The Effect of Eliminating Cost Sharing on Adolescent IUD Utilization [6F

INTRODUCTION: The Affordable Care Act (ACA) removed major cost barriers by expanding coverage to dependents and eliminating out of pocket costs (OOPC) for IUD placement. Our objective was to characterize the effect of eliminating OOPCs on IUD cost and placement among commercially-insured young women METHODS: This study used de-identified data from The Clinformatics™ Data Mart Database to examine changes in cost sharing and IUD placement among commercially-insured women ages 15-26 between 2009 and 2014. IUD placement was identified using ICD-9 and CPT-4 codes. Plans were categorized by cost sharing patterns: $0 OOPC, low OOPCs, and high OOPCs. Multilevel models were used to estimate the effect of cost sharing on IUD placement. RESULTS: We identified 604 unique plans that were utilized for IUD services in 2009 and 2014. The 75th percentile of OOPCs in 2009 was $241 and dropped to $0 in 2014. Average plan utilization rate increased significantly from 7.4% in 2009 to 10.3% in 2014 (p&lt;.001). When grouped by cost sharing patterns, significant increases in IUD utilization were observed for all groups. However, differences in plan utilization between 2009 and 2014 were not found. IUD plan utilization rate did not differ between plans with high OOPCs in 2009 and $0 in 2014 compared to plans that always had $0 OOPC (difference in slopes=.0115, p=.574). CONCLUSION: The elimination of cost sharing did not cause adolescents to increase IUD utilization beyond the general trend. Adolescents may be continuing to go outside their plans to access contraception despite the elimination of cost sharing.

The annual cost of not breastfeeding in Indonesia: the economic burden of treating diarrhea and respiratory disease among children (< 24mo) due to not breastfeeding according to recommendation

BackgroundIn Indonesia, 96% of children (< 24mo) are breastfed. However, only 42% of children (< 6mo) are exclusively breastfed, as per World Health Organization recommendations. Breastfeeding provides protective benefits such as reducing the risk of morbidity and mortality associated with diarrhea and pneumonia/respiratory disease (PRD). This study estimates the potential economic impact of not breastfeeding according to recommendation in Indonesia based on infants suffering from attributable diarrhea and PRD.MethodsA cost analysis examined both the healthcare system costs and non-medical costs for children (< 24mo) with diarrhea and PRD. Data collection took place between 2015 and 2016 and healthcare expenditures were assessed in 13 facilities, in five sites including Bandung and Tomohon City. Costs from a provider perspective were estimated using healthcare records and 26 interviews with healthcare workers. A discount rate of 3% was used. A cross-sectional survey with caregiver-child pairs (n = 615) collected data related to out of pocket costs such transportation and opportunity costs such as wage loss. These figures were combined with the national disease prevalence rates from Indonesia Demographic and Health Survey 2012, and the relative risk of disease of not breastfeeding according to recommendation from literatures to extrapolate the financial burden of treatment.ResultsThe healthcare system cost due to not breastfeeding according to recommendation was estimated at US$118 million annually. The mean healthcare system cost and out of pocket costs was US$11.37 and US$3.85 respectively. This cost consists of US$88.64 million of provider costs and US$29.98 million of non-medical patient costs.ConclusionsThe cost of not breastfeeding according to recommendation is potentially high, therefore the Indonesian government needs to invest in breastfeeding protection, promotion and support as the potential healthcare system cost savings are significant. As suggested by other studies, the long term cost due to cognitive losses of providing not breastfeeding according to recommendation should also be taken into account to provide a complete understanding of the economic impact of not breastfeeding according to recommendation.

Vaccination Perceptions of College Students: With and without Vaccination Waiver.

The resurgence of vaccine preventable diseases occurs more often among intentionally unvaccinated individuals, placing at direct risk young adults not caught up on vaccinations. The objectives of this study were to characterize the sociodemographic characteristics of young adults with and without vaccination waivers and identify their perceived benefits, barriers, and influencers of vaccination. Young adults (n = 964) from a Midwestern rural university responded to a survey (fall 2015-spring 2016) designed to identify their perception toward vaccination. Instrument consistency was measured using the Cronbach α-scores. The Chi-square test was used to test any sociodemographic differences and Mann-Whitney U-tests results for differences between exempt and non-exempt students. Analysis occurred in spring 2017. A little over one-third of young adults with a vaccination waiver were not up to date on their vaccinations, and think that vaccinations can cause autism. The biggest identifiable benefit was effective control against disease. The surveyed young adults ranked the out of pocket cost associated with vaccination as the most important barrier and safe and easy to use vaccines as the most important influencer of vaccination. Young adults who have had a vaccination waiver appear to not be up to date on their vaccinations. Vaccine administration programs, such as university campus clinics, would benefit from addressing perceptions unique to young adults with and without a vaccine waiver. This would subsequently better provide young adults a second shot for getting appropriately caught up on vaccinations.

Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana.

IntroductionThe free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored.MethodsA convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women’s perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes.ResultsThe NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy.ConclusionWomen needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.

Assessing the Effect of Adherence on Patient-reported Outcomes and Out of Pocket Costs Among Patients With Multiple Myeloma

BackgroundThe present study characterized the effect of multiple myeloma (MM) on work productivity, health care resource usage, and out of pocket costs (OOPCs) and examined the association of adherence with quality of life (QoL) and productivity loss. Materials and MethodsThe present cross-sectional study included 162 patients categorized by their 4-item Morisky Medication Adherence Scale (MMAS-4) score (4 vs. ≤ 3). Online surveys included the Work Productivity and Activity Impairment questionnaire, Functional Assessment of Cancer Therapy–Multiple Myeloma (FACT-MM), and MM-specific questions. ResultsOn average, patients reported FACT-MM scores of 98.5 ± 29.3, absenteeism of 18.3% ± 17.8%, presenteeism of 51.8% ± 30.2%, overall work productivity impairment of 57.3% ± 31.7%, and activity impairment of 49.9% ± 29.5% in the previous 7 days. During the previous 3 months, the mean OOPCs were $709 ± $1307; prescription medications accounted for 55% of these costs. Patients attended 4.1 ± 4.6 visits to oncologists or hematologists during that time, which accounted for 45% of the OOPCs. Patients spent an average of 6.8 ± 8.3 hours at MM-related monthly appointments, and 35.2% reported frustration while at the doctor’s office. Patients with an MMAS-4 score of 4 reported higher FACT-MM scores (106.9 vs. 89.2; P < .001). Patients with an MMAS-4 score of ≤ 3 reported greater activity impairment (56.5% vs. 39.8%; P = .015) and feeling overwhelmed or frustrated with rescheduling MM appointments (64.0% vs. 26.0%; P = .002). ConclusionMM was associated with significant workplace and functional impairment, high OOPCs, and frequent office visits. High medication adherence was associated with better outcomes across these domains. As survival for patients with MM improves, patient QoL should be considered to enhance these outcomes.

Stem Cell Therapy for COPD: Where are we?

Over the last year I have had several patients ask me about stem cell therapy for chronic obstructive pulmonary disease (COPD). There are clinics currently offering this therapy, (typically at exorbitant out of pocket cost to the patient), even though there are no phase III randomized controlled trials or Food and Drug Administration approval. There have been several phase I clinical trials, mostly looking at safety, and a handful of small phase II clinical trials that essentially have been negative. Despite this, there remains keen interest in continuing to study so-called “regenerative therapy” for COPD. Indeed, current standard therapies including bronchodilators and inhaled corticosteroids and the phosphodiesterase-4 inhibitor, roflumilast, show modest efficacy at best in reducing exacerbations and improving lung function. There has been no definitive evidence that they impact mortality. Lung volume reduction surgery is reserved often for those with severe disease and has only modest benefits. Lung transplantation is limited by availability, age restrictions, complications and rejection issues. With these limitations of standard modalities of therapy, it is attractive to pursue novel regenerative therapies that may be capable of restoring pulmonary function and structures such as airways, terminal bronchioles and alveoli. It is also postulated that by replacing these damaged cells there can be a restoration of normal immune function and a reduction in the inflammatory response to variable exposures such as cigarette smoke, air pollution and airway pathogens in susceptible individuals who develop COPD. Stem cells can differentiate into several different lung cell types such as the alveolar epithelial cells that are destroyed by cigarette smoke leading to emphysematous changes and reduced tethering of small airways causing hyperinflation and gas exchange abnormalities. Pre-clinical trials in animal models have suggested regeneration of alveolar-like structures, repair of emphysematous lungs, and reduction of inflammatory responses. The greatest success has been in acute lung injury models, however. Currently, regenerative therapies are divided into extrinsic therapeutic strategies and intrinsic cell therapy methods. There has been some work looking at the potential to bioengineer fully intact 3-D lung units that could be transplanted but this is not a likely prospect for the near future. Extrinsic cell therapy refers to infusing (or endotracheal installation) of stem cells including embryonic stem cells (ESCs), induced pleuripotent stem cells (iPSs), mesenchymal stem cells (MSCs), and human lung stem cells (hLSCs). Intrinsic therapy refers to the delivery of small molecules (retinoid compounds have been the most studied) that can stimulate the endogenous lung stem/progenitor cells to regenerate and replace damaged structures (See Sun et al review paper below). As mentioned above, human trials to date have largely failed in showing any benefit but there remain questions about appropriate candidates for such therapy, type of therapy, timing of therapy, dosing issues and a host of other variables that require further study. One of the salient questions is whether these therapies need to be started earlier in less severe stages of the disease process. Of course, if that is found to be the case then a major issue will be whether early identification, smoking cessation, adherence to conventional treatments and addressing comorbid conditions may be as or more effective. The papers presented in this Journal Club include an excellent, comprehensive state of the art review of the studies to date and the important future lines of research. The other recent papers address some of the questions raised in the review article. Note: Abstracts are presented in their original, published format and have not been edited to match JCOPDF style.

Health Care Use and Associated Time and Out of Pocket Expenditures for Patients With Cardiovascular Disease in a Publicly Funded Health Care System

BackgroundThe objectives of this study were to describe (1) health care use and associated patient time and out of pocket (OOP) costs over 2 years after a cardiac diagnosis, (2) the sociodemographic and clinical drivers of these costs, and (3) patient costs related to cardiac rehabilitation (CR) participation. MethodsSecondary analysis was conducted in an observational prospective CR program evaluation cohort in Ontario, which has a publicly funded health care system. A convenience sample of patients from 1 of 3 CR programs was approached at the first visit, and consenting participants completed a survey. Participants were e-mailed surveys again 6 months and 1 and 2 years later; these later surveys assessed their cardiac care and medications and the time and OOP costs associated with care visits. Patient time was valued based on average wages in Ontario. ResultsOf 411 consenting patients, 240 (58.3%) completed CR, and 192 (46.7%) were retained at 2 years. Patients most often visited a general practitioner and had electrocardiography and treatment for angina. The total cost to patients over 2 years was CAD$73.70 ± $275.84 for time and $377.01 ± $321.72 for OOP costs ($525.93 ± $467.08 overall). With adjustment, there were significantly higher OOP costs for women (P < 0.001) and less educated (P < 0.001) patients. Participants spent considerable money that was relatively OOP on CR visits alone ($384.78 ± $269.67), with time costs at $379.07 ± $1035.49 ($939.43 ± $1333.29 overall; 1.6% share of 1 year's income). ConclusionsIn conclusion, time and OOP costs are modest for patients with cardiac conditions, except for CR. Alternative delivery models are needed, in particular for low-income patients.

Financial Toxicity Concerns are Associated With Overall Levels of Patient Reported Distress During Radiation Therapy

We examined the association between patient reported financial toxicity (PRFT), Overall Survival (OS), and overall PRD in radiotherapy patients. 518 consecutive patients who underwent radiotherapy (RT) at an academic medical center between March 2012 and May 2016 were included in this retrospective study. Only patients were included. Information was collected regarding age at the start of RT, gender, type of RT (curative or palliative), cancer primary site, RT dose, metastatic disease, chemotherapy, surgery, and survival. Patient reported distress level was also assessed and ranges from 0 (the lowest) to 10 (the highest). Levels of concern regarding out of pocket costs and regarding finances were the primary measures of this study, and both of these measures were scored as either “not at all”, “a little bit”, “somewhat”, “quite a bit”, or “very much”. Baseline patient characteristics of these concerns were compared using Fisher’s exact test or a Kruskal-Wallis rank sum test. Associations between baseline patient characteristics and survival after the start of RT were evaluated using single variable (i.e. unadjusted) Cox proportional hazards regression models. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated. Associations of level of concern regarding out of pocket costs and level of concern regarding finances with survival after RT were evaluated using single variable and multivariable Cox proportional hazards regression models. Overall PRD level and concern regarding out of pocket costs were positively correlated (P<0.001). Additionally, there was a significant association between cancer primary site and level of concern regarding out of pocket costs (P=0.008), with level of concern highest for breast cancer, head and neck cancer, and musculoskeletal cancer. There were no other statistically significant associations between baseline characteristics and level of concern regarding out of pocket costs. Overall PRD level was significantly higher for patients expressing a greater level of concern regarding finances (P<0.001) as well as for younger patients (P=0.03). There was not a significant between either measures of financial distress in survival in single-variable analysis or in multivariable analysis adjusting for potential confounding variables. For curative RT patients, there was a significantly higher overall distress level as level of concern regarding out of pocket costs increased (P<0.001) and finances (P<0.001), but not for palliative RT patients for either measure. Correlations between concern for out of pocket costs and distress highlight the existence of sources of distress external to therapeutic treatments. The significance of younger patients reporting greater PRD scores also points to concern regarding early onset financial insecurity.

The Importance of Perspective When Evaluating The Economic Value of Vocational Rehabilitation

Objectives: The NICE reference case recommends economic evaluations take an NHS and Personal Social Services (PSS) perspective. This is appropriate if all of the associated costs and benefits are captured, however less so, when a proportion lie outside of healthcare. We aim to explore the importance of perspective in the FRESH trial. This trial assessed the feasibility of delivering a full scale trial evaluating the (cost) effectiveness of Vocational Rehabilitation (VR), an individualised return to work programme, amongst Traumatic Brain Injury patients in comparison to usual care, across three trauma centres in England. Methods: This feasibility study compared alternative methods of collecting and valuing resource use data, which included taking two perspectives: NHS and PSS, plus a societal perspective. Several methods were used to estimate time off work costs, for example using national average hourly wage rates compared to participant reported earnings, as well as valuing presenteeism through the Workers Productivity and Activity Impairment instrument compared to bespoke questions. Results: When societal costs were considered, such as government employment services, time off work and out of pocket costs, the broader costs accounted for 61.77% of total costs in the VR group, compared to 80.90% within usual care. Though these percentages varied according to methods used, they demonstrate that within any full-scale economic evaluation conducted, it is likely that the largest cost-drivers will occur using a societal perspective. Taking a broader perspective adds complexity to an evaluation in terms of appropriately capturing the data and in identifying sources of unit costs. Conclusions: Using a limited perspective where significant costs and benefits are believed to lie outside healthcare could lead to erroneous estimates of value for money and poor value from public funding. Further research is required to inform how such wider resource items should be measured and valued.

The End of Life Option Act: Important Considerations for Pharmacists as California Implements Physician Aid in Dying

The End of Life Option Act: Important Considerations for Pharmacists as California Implements Physician Aid in Dying

The socio-economic burden of snakebite in Sri Lanka

BackgroundSnakebite is a major problem affecting the rural poor in many of the poorest countries in the tropics. However, the scale of the socio-economic burden has rarely been studied. We undertook a comprehensive assessment of the burden in Sri Lanka.MethodsData from a representative nation-wide community based household survey were used to estimate the number of bites and deaths nationally, and household and out of pocket costs were derived from household questionnaires. Health system costs were obtained from hospital cost accounting systems and estimates of antivenom usage. DALYs lost to snakebite were estimated using standard approaches using disability weights for poisoning.Findings79% of victims suffered economic loss following a snakebite with a median out of pocket expenditure of $11.82 (IQR 2–28.57) and a median estimated loss of income of $28.57 and $33.21 for those in employment or self-employment, respectively. Family members also lost income to help care for patients. Estimated health system costs for Sri Lanka were $ 10,260,652 annually. The annual estimated total number of DALYS was 11,101 to 15,076 per year for envenoming following snakebite.InterpretationSnakebite places a considerable economic burden on the households of victims in Sri Lanka, despite a health system which is accessible and free at the point of care. The disability burden is also considerable, similar to that of meningitis or dengue, although the relatively low case fatality rate and limited physical sequelae following bites by Sri Lankan snakes means that this burden may be less than in countries on the African continent.

Financial toxicity and cancer-related distress among melanoma survivors.

9588 Background: Melanoma survivors are at risk for significant financial burden due to cancer care and out of pocket costs. We explored 1) the financial impact of melanoma and its relationship to cancer-related distress, and 2) survivors’ experiences discussing financial burden with their health care team. Methods: Of 110 melanoma survivors enrolled in the Cancer Support Community’s online Cancer Experience Registry, 56 completed questions about financial impact of cancer and cost of care communication. Participants rated concern (0 = not at all; 4 = very seriously) about 27 items encompassing psychological, emotional, physical and practical concerns; items were summed into a total distress score (mean = 33, SD = 21, range 0-88). Financial impact and overall distress were examined via regression analysis. Results: Participants were 71% female, 89% Caucasian, median age 54, and median time since diagnosis 2.5 years. Total annual income: 34% &lt; $60K; 46% $60K+; 20% not reported. 24% spent $101-250/month on melanoma out of pocket costs; 20% spent $251-500; and 24% spent ≥$500. The top concern was health insurance/money worries (69% moderately to very seriously concerned). Due to medical costs, 57% depleted their savings, 20% borrowed against or used retirement money, 20% used pharmaceutical assistance programs, 13% skipped medicine dosages at least sometimes, and 17% postponed filling prescriptions. Only 28% reported that their health care team spoke to them about cost of care, and 28% were asked about financial distress; 42% desired financial assistance. Financial impact was associated with an increase in overall distress for those with income &lt; $60K (p &lt; .05; interaction p &lt; 0.05). Conclusions: Substantial proportions of melanoma survivors experience financial burden that can impact quality of life, particularly lower income individuals. Although oncologists are encouraged to discuss treatment costs, most patients report they have not had these discussions with providers. These results support the development/evaluation of interventions to enhance doctor-patient communication, and financial counseling to minimize financial burden of melanoma and the risks it can confer for quality of life, course of cancer care, and health outcomes.

Approaches to appropriate care delivery from a policy perspective: A case study of Australia, England and Switzerland

BackgroundAppropriateness is a conceptual way for health systems to balance Triple Aim priorities for improving population health, containing per capita cost, and improving the patient experience of care. Comparing system approaches to appropriate care delivery can help health systems establish priorities and facilitate appropriate care practices. MethodsWe conceptualized system appropriateness by identifying policies that aim to achieve the Triple Aim and their consequent trade-offs for financing, clinical practice, and the individual patient. We used secondary data sources to compare the appropriate care approaches of Australia, England, and Switzerland according to financial, clinical, and individual appropriateness policies. FindingsHealth system approaches to appropriate care delivery varied. England prioritizes public health, equity and efficiency at the expense of individual choice, while Switzerland focuses on individual patient preferences, but has higher per capita and out of pocket costs. Australia provides equity in public care access and private health care options that allows for more patient choice, with health care costs falling between the two. ConclusionsIntegrating the Triple Aim into health system design and policy can facilitate appropriate care delivery at the system, clinical, and individual levels. Approaches will vary and require countries to negotiate and justify priorities and trade-offs within the context of thehealth system.