key: cord-0708613-5f53vdj0
authors: Cwalina, Thomas B.; Jella, Tarun K.; Tripathi, Raghav; Carroll, Bryan T.
title: Financial stress among skin cancer patients: a cross-sectional review of the 2013–2018 National Health Interview Survey
date: 2022-02-22
journal: Arch Dermatol Res
DOI: 10.1007/s00403-022-02330-6
sha: 014bb8a1ba4c7a6fc34ee0714a8e35dc16f5347c
doc_id: 708613
cord_uid: 5f53vdj0

Financial stress among skin cancer patients may limit treatment efficacy by forcing the postponement of care or decreasing adherence to dermatologist recommendations. Limited information is available quantifying the anxiety experienced by skin cancer patients from both healthcare and non-healthcare factors. Therefore, the present study sought to perform a retrospective cross-sectional review of the 2013–2018 cycles of the National Health Interview Survey (NHIS) to determine the prevalence, at-risk groups, and predictive factors of skin cancer patient financial stress. Survey responses estimated that 11.45% (95% Cl 10.02–12.88%) of skin cancer patients experience problems paying medical bills, 20.34% (95% Cl 18.97–21.71%) of patients worry about the medical costs, 13.73% (95% Cl 12.55–14.91%) of patients worry about housing costs, and 37.48% (95% Cl 35.83–39.14%) of patients worry about money for retirement. Focusing on at-risk groups, black patients, uninsured patients, and patients with low incomes (< 200% poverty level) consistently experienced high rates of financial stress for each of the four measures. Multivariable logistic regression revealed low education, lack of insurance, and low income to be predictive of financial stress. These findings suggest that a considerable proportion of skin cancer patients experience financial stress related to both healthcare and non-healthcare factors. Where possible, the additional intricacy of treating patients at risk of high financial stress may be considered to optimize patient experience and outcomes.

The impact of financial stress within the field of dermatology and dermatologic oncology is of particular importance due to the increasing prevalence of skin cancer and the higher amount of out-of-pocket costs these patients may experience [1] [2] [3] [4] . A study analyzing over 9 million new cancer diagnoses between 2000 and 2012 estimated that in the first two years following their diagnosis, 42.4% of patients reported depleting their life savings [5] . These high expenditures can often increase patients' worries and anxieties, which can further worsen their wellbeing and exacerbate disparities [1] . Since financial stress can limit the effectiveness of clinical treatment greatly, increasing efforts have been made to screen for financial stress factors and align treatment plans to a patient's situation [6, 7] .

Previous research has analyzed the troubling impacts of low socioeconomic status on skin cancer outcome disparities [8] [9] [10] . However, few prior investigations have been able to quantify the potential financial stress reported directly from skin cancer patients, from both healthcare and nonhealthcare factors. It is hypothesized that within the skin cancer population a considerable portion of patients experiences financial stress, with factors such as health status, income, and insurance serving as predictors. Therefore, the present study sought to perform a cross-sectional review of the National Health Interview Survey (NHIS) to quantify the prevalence of various financial stress measures among skin cancer patients, identify subgroups affected most by personal financial stress, and isolate the most predictive features of skin cancer patients experiencing financial stress.

This study was conducted across the 2013 to 2018 cycles of the National Health Interview Survey (NHIS), a nationally representative survey conducted annually by the National Center for Health Statistics (NCHS) [11] . Using complex sampling design techniques such as stratification and clustering, the NHIS collects estimates of a wide range of health information for the civilian noninstitutionalized population of the United States. With over 600 unique questions included, the NHIS has been employed to analyze health concerns from a patient's perspective [12] [13] [14] [15] . Since, 2013 the NHIS included financial stress questions about the following topics: "problems paying or unable to pay medical bills, past 12 months"; "worried about the medical costs of health care"; "worried about paying rent/mortgage/housing costs"; "worried about money for retirement". For the first question about "problems paying or unable to pay medical bills, past 12 months", responses were structured in a yes/ no format. For the remaining three questions about financial worries, responses were structured in a four-step scale indicating the amount of worry: "not worried at all", "not too worried", "moderately worried", or "very worried".

These respondents from the NHIS were then filtered to only include those who reported having ever been told by a doctor or other health care professional that they had a form of skin cancer (melanoma or non-melanoma) [16] . Within this subset of patients, only those who completed a response to the aforementioned financial security questions were included. Finally, the responses to the four-step scale questions about financial worries were then binarized into "not worried at all"/"not too worried" and "moderately worried"/"very worried" according to previous analysis of the NHIS to increase compatibility for statistical analysis [17] .

First, this subset of skin cancer patients was then analyzed to see the prevalence of financial stress concerns among the population. The overall proportions of the responses were calculated for all four financial stress questions, including their 95% confidence intervals. Next, the data was analyzed for any crude differences in financial stress responses based on the independent variables included in the study. The 95% confidence intervals were calculated for the breakdowns and statistical significance was determined using a Pearson X 2 test with the Rao Scott adjustment [18] . To account for potential confounding factors, a multivariable analysis was conducted using logistic regression while controlling for all the independent variables to predict the financial stress responses. From this regression, the adjusted odds ratios with 95% confidence intervals were calculated and statistical significance was determined using the Wald test [19] .

Statistical analysis was conducted using R version 4.0.2. All statistical calculations accounted for the complex sampling design of the NHIS using the R "survey" package (version 4.0). Finally, statistical tests were two-sided, and significance was defined as p < 0.05.

The unconditional response rate of the survey ranged from 64.2 to 75.7% over the study period. The cohort of skin cancer patients who responded to the four survey questionsproblems paying medical bills, worried about the medical costs, worried about housing costs, and worried about money for retirement-included a total of 5698, 5601, 5605, 5604 patients, respectively. The average age for all question cohorts was 65 years old. 96% of respondents in all cohorts were non-Hispanic white. In addition, 48% of respondents were female in all cohorts ( 

This analysis identified the prevalence, at-risk groups, and potential predictive factors for various measures of healthcare and non-healthcare financial stress. Based on the analysis, a considerable percentage of skin cancer patients experience difficulty paying medical bills and even more worry about medical costs. In addition, numerous skin cancer patients worry about financial costs outside of healthcare, which only adds to the overall anxiety these patients may experience. Disparities also exist within each financial stress response when stratified by subgroups. Those patients who were uninsured were consistently the most affected, followed by black patients and patients with income below 200% of the federal poverty level. Previous research has demonstrated disparities within these groups in skin cancer outcomes [8] . While skin cancer outcome disparities are complex and multifactorial, the high amount of financial stress within these groups highlights an upstream cause and primary area for improvement.

The results from the multivariable logistic regression provide additional information as to which patients are most likely to be experiencing financial stress, controlling for potential confounding. It was hypothesized, based upon previous research in other fields, that poor health, a lack of insurance, and low education would be most predictive of financial stress [13, 20] . This study finds similar results: self-reported health status, insurance, and highest educational attainment were consistently predictive of financial stress. Those with poor/fair self-reported health, those with lower educational attainment, and those without insurance were more likely to experience financial stress. In addition, it was found that income level was determined to be highly predictive within skin cancer patients. Efforts to improve disparities should focus on these core determinants of financial stress, without ignoring the complex interplay of additional socioeconomic and structural factors.

Other studies have discussed the improvement and contextualization of care to those patients affected by lower socioeconomic factors and other social determinants. One option which has been discussed is routine screening for financial vulnerability across entire patient populations, with the goal of referral to community-based support and social assistance programs [6, 7, 21] . However, such interventions must be contextualized within existing administrative structures and the potential complexities of implementation, such as the growth of overhead costs or potential reinforcement of harmful stereotypes [7, 21, 22] . Some institutions have begun validating healthcare-related financial stress as a discrete patient-reported outcome metric, expanding opportunities for payment model innovation and more specific risk stratification [23, 24] . Other researchers have suggested teledermatology as a potentially useful tool to help the socioeconomically disadvantaged [8] . However, as the surgical nature of diagnosis and treatment of skin cancer requires in-person visits, teledermatology alone is inadequate to treat these patients. Additionally, technological solutions may be incomplete wherever the cost reductions are not effectively translated to financially struggling patients [2] .

Our study has limitations. There were low percentages of minority patients within the sample of skin cancer patients answering the financial stress survey questions. While this smaller sample is reflective of previous research demonstrating a lower skin cancer prevalence in minority populations, adequate sampling is necessary to achieve statistical power to completely analyze financial stress within these groups [25] . Future studies with focused recruitment of minority skin cancer patients should be conducted to understand how financial stress may affect care and disparities within these populations. In addition, this study does not include financial stress information collected during the coronavirus pandemic and economic lockdown. These events have the potential to greatly affect the financial stress of the United States population and worsen disparities due to the pandemic's disproportionate effects on poorer and more diverse populations [26] . Finally, the nature of the cross-sectional study design limits the ability to draw a direct causal relationship between patient-reported financial stress and terminal outcome measures. Nevertheless, the present study is provided strength by a large sample size, nationally representative cohort, as well as the methodological rigor and sampling design of the NHIS dataset.

The present retrospective cross-sectional review of the 2013 to 2018 cycles of the National Health Interview Survey investigates the prevalence of financial stress among the skin cancer population within the United States. Where possible, additional resources directed towards at-risk skin cancer patients may best serve their unique socioeconomic contexts. Although financial stress has been hypothesized to correlate with poorer treatment outcomes within this patient population, the mechanism and magnitude of this relationship have yet to be rigorously studied. The degree to which skin cancer patients experience financial stress as a direct result of out-of-pocket dermatologic expenses also remains unclear. Whereas the present study is limited to a retrospective cross-sectional design, future investigations should organize a prospective multi-institutional cohort aimed at comparing the effects of various levels of financial stress on intermediate and terminal outcomes such as loss to follow-up, treatment failure, and survival. Additionally, future research efforts should analyze the effectiveness of the implementation of various financial assistance programs, along with patient-centered qualitative research to identify areas to more completely support patients.

A considerable proportion of skin cancer patients experience financial stress related to both healthcare and non-healthcare factors. This stress may limit treatment efficacy by forcing the postponement of care and decreasing the ability to follow dermatologist recommendations. These findings highlight the importance of contextualizing care of patients at risk of high financial stress to optimize patient experience and outcomes.

Author contributions All authors contributed to the study's conception and design. Material preparation, data collection, and analysis were performed by TBC. The first draft of the manuscript was written by TBC and TKJ, and all authors commented on previous versions of the manuscript. TBC takes responsibility for the paper as a whole.

Funding There was no specific funding for this research.

Availability of data and material The data are publicly available from the website of the National Center for Health Statistics (NCHS).

Code availability Upon request.

The authors declare no relevant conflicts of interest.

Ethics approval This study was deemed exempt by the University Hospitals Cleveland Medical Center Institutional Review Board.

Consent for publication Not applicable.

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