Interventions to mitigate cancer-related medical financial hardship: A systematic review and meta-analysis.

BACKGROUND: This study systematically reviewed interventions mitigating financial hardship in patients with cancer and assessed effectiveness using a meta-analytic method. METHODS: PubMed, Cochrane, Scopus, CINAHL, and Web of Science were searched for articles published in English during January 2000-April 2023. Two independent reviewers selected prospective clinical trials with an intervention targeting and an outcome measuring financial hardship. Quality appraisal and data extraction were performed independently by two reviewers using a quality assessment tool. A random-effects model meta-analysis was performed. Reporting followed the preferred reporting items for systematic review and meta-analyses guidelines. RESULTS: Eleven studies (2211 participants; 55% male; mean age, 59.29 years) testing interventions including financial navigation, financial education, and cost discussion were included. Financial worry improved in only 27.3% of 11 studies. Material hardship and cost-related care nonadherence remained unchanged in the two studies measuring these outcomes. Four studies (373 participants; 37% male, mean age, 55.88 years) assessed the impact of financial navigation on financial worry using the comprehensive score of financial toxicity (COST) measure (score range, 0-44; higher score = lower financial worry) and were used for meta-analysis. There was no significant change in the mean of pooled COST score between post- and pre-intervention (1.21; 95% confidence interval, -6.54 to 8.96; p = .65). Adjusting for pre-intervention COST, mean change of COST significantly decreased by 0.88 with every 1-unit increase in pre-intervention COST (p = .02). The intervention significantly changed COST score when pre-intervention COST was ≤14.5. CONCLUSION: A variety of interventions have been tested to mitigate financial hardship. Financial navigation can mitigate financial worry among high-risk patients.

Sociodemographic Factors Associated with Outpatient Radiology No-shows Versus Cancellations.

RATIONALE AND OBJECTIVES: To assess prevalence of missed outpatient radiology appointments and sociodemographic factors associated with no-shows vs. cancellations. METHODS: Adults with outpatient radiology appointments in 2022 and January 2023 at a single tertiary academic health center were included. Generalized estimating equation regression was used to evaluate sociodemographic factors associated with missed vs. completed appointments, no-shows vs. cancellations and time interval between cancellations and appointments. RESULTS: 19,262 (24.3%) examinations were either a cancellation (22.3%) or no-show (2.0%) among 9713 patients (mean age 60.8 ± 15.5; 67.1% female, 63.9% White, 20.0% Asian, 22.0% Hispanics). Among cancellations, 70.19% were patient-initiated. Age ≥ 65 significantly decreased the probability of missed appointments by 5.4% point (pp) (95% CI: 3.7-7.2) or no-shows (4.2 pp; 95% CI, 1.4-6.9), while being single increased probability of missed appointments (2.2 pp; 95% CI, 1.2-3.1) or no-shows (2.6 pp; 95% CI, 1.2-4.1). Those uninsured or with public insurance were 1.3-4.9 pp more likely to miss appointments than commercial insurance, and 2.2-7.6 pp more likely to have no-shows than cancellations. Living in disadvantaged neighborhoods 4.9 pp (95% CI, 3.9-6.0) increased likelihood of missing appointment and was associated with shorter time interval between cancellation and appointment. English speakers were 2.2 pp (95% CI, 1.1-3.3) more likely to miss their exam, while 2.7 pp (95% CI, 1.1-0.4.3) less likely to be a no-show than cancellation. CONCLUSION: Cancellations represented a significant portion of missed appointments. Specific sociodemographic subgroups exhibited higher tendencies for having missed appointments and no-shows.

Interrater Agreement of BT-RADS for Evaluation of Follow-Up MRI in Treated Primary Brain Tumor Patients.

BACKGROUND AND PURPOSE: The Brain Tumor Reporting and Data System (BT-RADS) is a structured radiology reporting algorithm that was introduced to provide uniformity in post-treatment primary brain tumor follow-up and reporting, but its interrater reliability (IRR) assessment has not been widely studied. Our goal is to evaluate the IRR among neuroradiologists and radiology residents in the use of BT-RADS. MATERIALS AND METHODS: This retrospective study reviewed 103 consecutive MR studies in 98 adult patients previously diagnosed with and treated for primary brain tumor (January 2019 to February 2019). Six readers with varied experience (4 neuroradiologists and 2 radiology residents) independently evaluated each case and assigned a BT-RADS score. Readers were blinded to the original score reports and the reports from other readers. Cases in which at least one neuroradiologist scored differently were subjected to consensus scoring. After the study, a post-hoc reference score was also assigned by 2 readers using future imaging and clinical information previously unavailable to readers. The interrater reliabilities were assessed using Gwet's AC2 index with ordinal weights and percent agreement. RESULTS: Of the 98 patients evaluated (median age, 53 years; interquartile range, 41-66 years), 53% were males. The most common tumor type was astrocytoma (77%) of which 56% were grade 4 glioblastoma. Gwet's index for interrater reliability among all six readers was 0.83 (95% CI: 0.78, 0.87). The Gwet's index for the neuroradiologists' group (0.84 [95% CI: 0.79, 0.89]) was not statistically different from that for the residents' group (0.79 [95% CI: 0.72, 0.86]) (χ2 = 0.85; p = 0.36). All four neuroradiologists agreed on the same BT-RADS score in 57 of the 103 studies, three neuroradiologists agreed in 21 of the 103 studies, and two neuroradiologists agreed in 21 of the 103 studies. Percent agreement between neuroradiologist blinded scores and post-hoc reference scores ranged from 41%-52%. CONCLUSIONS: A very good interrater agreement was found when tumor reports were interpreted by independent blinded readers using BT-RADS criteria. Further study is needed to determine if this high overall agreement can translate into greater consistency in clinical care. ABBREVIATIONS: BI-RADS = Breast Imaging Reporting and Data System; BT-RADS = Brain Tumor Reporting and Data System; IQR = interquartile range; IRR = interrater reliability; NI-RADS = Neck Imaging Reporting and Data System.

Racial Disparities and Other Socioeconomic Predictors of Mortality in Acute Pulmonary Embolism Treatment from the National Inpatient Sample.

PURPOSE: To explore the significance of socioeconomic factors such as race and ethnicity as predictors of mortality in sub-massive and massive acute pulmonary embolism (PE). MATERIALS AND METHODS: Hospitalizations aged > 18 years with acute, non-septic PE from 2016 to 2019 were identified in the National Inpatient Sample and divided into IR (CDT and thrombectomy) and non-IR (tPA) treatments. Statistical analyses calculated significant odds ratios via 95% confidence intervals. The primary outcome of interest was mortality rate. Comorbidities affecting mortality were examined secondarily. RESULTS: Non-Hispanic (NH) Black, Hispanic, and Asian/Pacific Islander patients were significantly less likely to undergo an IR procedure for acute, non-septic PE compared to White patients (NH Black 0.83 [0.76 - 0.90], p<0.05; Hispanic 0.78 [0.68 - 0.89], p=0.06; Asian/Pacific Islander 0.71 [0.51 - 0.98], p=0.72; OR [95% CI]); however, these differences were eliminated when propensity score matching for age, biological sex, and primary insurance-type or primary insurance-type alone. NH Black patients were significantly more likely than White patients to die regardless of undergoing non-IR or an IR treatment. Overall risk of death was 41% higher for NH Black patients compared to White patients (RR [95% CI] 1.41 [1.24 - 1.60], p<0.001). CONCLUSION: NH Black patients have a higher risk of mortality from acute, non-septic PE than White patients. Independent of race, undergoing IR management for acute, non-septic pulmonary embolisms was associated with a lower mortality rate. Matching for primary insurance-type eliminates difference in mortality between races suggest socioeconomic status (SES) may determine outcomes in acute PE.

Patient-Provider Lung Cancer Screening Discussions: An Analysis of a National Survey.

BACKGROUND: The US Preventative Service Task Force (USPSTF) updated lung cancer screening (LCS) recommendations with annual low-dose CT (LDCT) in 2021. We aimed to assess prevalence of patient-provider discussion about LCS and determine its associated factors. MATERIALS AND METHODS: Using data from Health Information National Trends Survey (HINTS) 2022 cycle 6, 2 cohorts were evaluated: (1) potentially LCS-eligible, included participants at least 50 years old with a history of smoking and no prior history of lung cancer; (2) LCS-ineligible individuals based on age (eg, 18-49 years old), smoking history (eg, never smoked), or history of lung cancer. We assessed association of demographic, clinical, and social factors with LDCT discussion in a multivariable logistic regression model. RESULTS: Among potentially LCS-eligible patients, 19% had never heard of LDCT and only 9.4% had discussed LCS with their provider within the past year. Those who accessed online patient portals were more likely to discuss LCS with their healthcare provider (OR, 4.25; 95% CI, 1.67, 10.81; P, .003), as were respondents with a history of current (vs. former) smoking (OR, 3.15; 95% CI, 1.21, 8.19; P, .019). Among LCS-ineligible, 1.9% discussed LCS with their providers. Individuals with a personal history of cancer (OR, 6.70; 95% CI, 1.65, 27.19; P, .009), and those who discussed colorectal cancer screening (OR, 5.74; 95% CI, 1.63, 20.14; P, .007) were more likely to discuss LCS with their provider. CONCLUSION: Despite updated USPSTF recommendations, rates of patient-provider LCS remains low. Multi-level interventions to address barriers to LCS are needed.

Interventions addressing health-related social needs among patients with cancer.

Health-related social needs are prevalent among cancer patients; associated with substantial negative health consequences; and drive pervasive inequities in cancer incidence, severity, treatment choices and decisions, and outcomes. To address the lack of clinical trial evidence to guide health-related social needs interventions among cancer patients, the National Cancer Institute Cancer Care Delivery Research Steering Committee convened experts to participate in a clinical trials planning meeting with the goal of designing studies to screen for and address health-related social needs among cancer patients. In this commentary, we discuss the rationale for, and challenges of, designing and testing health-related social needs interventions in alignment with the National Academy of Sciences, Engineering, and Medicine 5As framework. Evidence for food, housing, utilities, interpersonal safety, and transportation health-related social needs interventions is analyzed. Evidence regarding health-related social needs and delivery of health-related social needs interventions differs in maturity and applicability to cancer context, with transportation problems having the most maturity and interpersonal safety the least. We offer practical recommendations for health-related social needs interventions among cancer patients and the caregivers, families, and friends who support their health-related social needs. Cross-cutting (ie, health-related social needs agnostic) recommendations include leveraging navigation (eg, people, technology) to identify, refer, and deliver health-related social needs interventions; addressing health-related social needs through multilevel interventions; and recognizing that health-related social needs are states, not traits, that fluctuate over time. Health-related social needs-specific interventions are recommended, and pros and cons of addressing more than one health-related social needs concurrently are characterized. Considerations for collaborating with community partners are highlighted. The need for careful planning, strong partners, and funding is stressed. Finally, we outline a future research agenda to address evidence gaps.

Patient-Reported Financial Burden of Treatment for Colon or Rectal Cancer.

Importance: The longitudinal experience of patients is critical to the development of interventions to identify and reduce financial hardship. Objective: To evaluate financial hardship over 12 months in patients with newly diagnosed colorectal cancer (CRC) undergoing curative-intent therapy. Design, Setting, and Participants: This prospective, longitudinal cohort study was conducted between May 2018 and July 2020, with time points over 12 months. Participants included patients at National Cance Institute Community Oncology Research Program sites. Eligibility criteria included age at least 18 years, newly diagnosed stage I to III CRC, not started chemotherapy and/or radiation, treated with curative intent, and able to speak English. Data were analyzed from December 2022 through April 2023. Main Outcomes and Measures: The primary end point was financial hardship, measured using the Comprehensive Score for Financial Toxicity (COST), which assesses the psychological domain of financial hardship (range, 0-44; higher score indicates better financial well-being). Participants completed 30-minute surveys (online or paper) at baseline and 3, 6, and 12 months. Results: A total of 450 participants (mean [SD] age, 61.0 [12.0] years; 240 [53.3%] male) completed the baseline survey; 33 participants (7.3%) were Black and 379 participants (84.2%) were White, and 14 participants (3.1%) identified as Hispanic or Latino and 424 participants (94.2%) identified as neither Hispanic nor Latino. There were 192 participants (42.7%) with an annual household income of $60 000 or greater. There was an improvement in financial hardship from diagnosis to 12 months of 0.3 (95% CI, 0.2 to 0.3) points per month (P < .001). Patients with better quality of life and greater self-efficacy had less financial toxicity. Each 1-unit increase in Functional Assessment of Cancer Therapy-General (rapid version) score was associated with an increase of 0.7 (95% CI, 0.5 to 0.9) points in COST score (P < .001); each 1-unit increase in self-efficacy associated with an increase of 0.6 (95% CI, 0.2 to 1.0) points in COST score (P = .006). Patients who lived in areas with lower neighborhood socioeconomic status had greater financial toxicity. Neighborhood deprivation index was associated with a decrease of 0.3 (95% CI, -0.5 to -0.1) points in COST score (P = .009). Conclusions and Relevance: These findings suggest that interventions for financial toxicity in cancer care should focus on counseling to improve self-efficacy and mitigate financial worry and screening for these interventions should include patients at higher risk of financial burden.

Patients, practice, and price transparency: The impact of disclosing healthcare costs on consumer decision-making.

The introduction of price transparency mandates by the Center for Medicare and Medicaid Services (CMS) aimed to reduce healthcare spending by promoting price comparison and the selection of lower-cost providers. In this brief communication, we will discuss how consumer interests in price comparison are influenced and how price transparency is expected to impact consumer decision-making with specific examples for imaging as a shoppable service.

Role of Online Patient Portal Self-Scheduling and Self-Referral Pathways to Decrease Health Disparity for Screening Mammography.

PURPOSE: The aim of this study was to assess the rate of self-scheduling and self-referral for screening mammography and to assess sociodemographic factors associated with their use in an academic health care system in southern California. METHODS: Patients scheduled for screening mammography between February 1, 2021, and September 20, 2022, were included in this retrospective study. Multivariable logistic regression models were used to assess associations among sociodemographic factors, self-referral, and online self-scheduling pathways. RESULTS: In total, 22,306 patients were scheduled for screening mammography (mean age, 59 years; 66.8% White, 20.4% Asian, and 20.6% Hispanic). Overall, 3,566 (16.0%) used online self-scheduling, and 1,232 (5.5%) self-referred for screening mammography. Patients 70 years or older (versus 50 years or younger) (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.34-0.51), Spanish (versus English) speakers (OR, 0.22; 95% CI, 0.16-0.31), and those on Medicaid (versus commercially insured) (OR, 0.71; 95% CI, 0.50-0.99) were less likely to self-schedule. Hispanic patients (versus non-Hispanic) (OR, 1.39; 95% CI, 1.20-1.61), Asian patients (versus White) (OR, 1.64; 95% CI, 1.46-1.85), and patients residing in the most (versus least) disadvantaged neighborhoods (OR, 1.16; 95% CI, 1.02-1.33) were more likely to self-schedule. Furthermore, patients 70 years or older (versus 50 or younger) (OR, 0.70; 95% CI, 0.52-0.93) and Spanish speakers (OR, 0.05; 95% CI, 0.03-0.09) were less likely to self-refer, whereas Black patients (versus White) (OR, 1.89; 95% CI, 1.30-2.75), patients on Medicaid (versus commercially insured) (OR, 3.70; 95% CI, 2.65-5.13), and patients living in the most (versus least) disadvantaged neighborhoods (OR, 1.52; 95% CI, 1.27-1.82) were more likely to self-refer. CONCLUSIONS: Sociodemographic differences in online patient portal use and self-referral for screening mammography suggest that the two pathways have been successful in addressing some of the existing scheduling barriers and are a step toward closing the disparity gap.

Feasibility of Screening for Financial Hardship and Health-Related Social Needs at Radiology Encounters.

OBJECTIVE: To evaluate the prevalence of financial hardship and health-related social needs (HRSNs) among outpatients undergoing advanced imaging services and assess the feasibility of screening for financial and social needs during radiology encounters. METHODS: Adult patients receiving CT, MRI, or PET/CT at outpatient imaging centers of an academic tertiary center were asked to complete a 15-minute survey with adapted validated questions inquiring about their experience of financial hardship related to imaging and HRSNs, and the appropriateness of screening for financial and social needs at radiology encounters. Logistic regression analyses were performed to assess factors associated with perceived appropriateness of screening and level of interest in meeting with financial counselors. RESULTS: A total of 430 patients responded (10.0% response rate; mean age: 57.1 years; 57.4% female; 54.5% White; 22.1% Hispanic; 19.1% Asian; 1% Black). A total of 35% reported experiencing financial hardship with imaging; 47.5% reported material hardship, 15.3% reported cost-related care nonadherence, and 5.3% reported cost-related imaging nonadherence. Overall, 35.9% had at least one HRSN, with food insecurity being the most common (28.3%). The majority (79.7%) felt that being screened for HRSNs at radiology encounters is appropriate, with those experiencing imaging hardship being more likely to feel that screening is appropriate (odds ratio [OR]: 2.93; 95% confidence interval [CI], 1.31-6.56). Overall, 29.5% were interested in meeting with a financial counselor, with those with imaging hardship (OR: 3.70; 95% CI, 1.96-6.97) and HRSNs (OR: 2.87; 95% CI, 1.32-6.24) and who felt uncomfortable with screening (OR: 2.83; 95% CI, 1.14-7.03) being more likely to be interested. DISCUSSION: Financial hardship and HRSNs are common among outpatients undergoing advanced imaging, with the majority reporting that getting screened at radiology encounters is appropriate.

Healthcare price transparency in North America and Europe.

Healthcare price transparency is an effort to inform patient decision-making, but also to decrease prices and their variation across healthcare systems for equivalent medical services. The initiative is meaningful only for medical services that are shoppable-such as imaging examinations-for which patients incur out-of-pocket costs. Therefore, several countries in which patients commonly share a portion of their healthcare costs have been implementing mandates to improve healthcare price transparency. However, the provisional implementation has many issues, especially in the United States, including provider non-compliance and limited accessibility of price transparency tools by the general public. Many of the existing tools are not user-friendly, are difficult to navigate, focus on charges and health plan negotiated rates rather than patients' out-of-pocket costs, and disclose prices on the service level instead of per episode of care. As such, the disclosed amounts are often not reliable. Many price transparency tools also lack valid and measurable quality metrics, which can result in a selection of high-cost care as a proxy for high-value care, as well as an increase in healthcare prices when providers want to imply they offer high-quality care. Nevertheless, the impact of the initiatives on patients' decision-making and healthcare costs remains unclear. While transparency initiatives are patient-centric, efforts should be made to increase patient engagement, provide accurate patient-specific out-of-pocket cost information, compare available treatment and provider alternatives, and couple price information with quality metrics to enable making fully informed decisions.

Using Brain Tumor MRI Structured Reporting to Quantify the Impact of Imaging on Brain Tumor Boards.

Multidisciplinary tumor boards (TB) are an essential part of brain tumor care, but quantifying the impact of imaging on patient management is challenging due to treatment complexity and a lack of quantitative outcome measures. This work uses a structured reporting system for classifying brain tumor MRIs, the brain tumor reporting and data system (BT-RADS), in a TB setting to prospectively assess the impact of imaging review on patient management. Published criteria were used to prospectively assign three separate BT-RADS scores (an initial radiology report, secondary TB presenter review, and TB consensus) to brain MRIs reviewed at an adult brain TB. Clinical recommendations at TB were noted and management changes within 90 days after TB were determined by chart review. In total, 212 MRIs in 130 patients (median age = 57 years) were reviewed. Agreement was 82.2% between report and presenter, 79.0% between report and consensus, and 90.1% between presenter and consensus. Rates of management change increased with increasing BT-RADS scores (0-3.1%, 1a-0%, 1b-66.7%, 2-8.3%, 3a-38.5%, 3b-55.9, 3c-92.0%, and 4-95.6%). Of 184 (86.8%) cases with clinical follow-up within 90 days after the tumor board, 155 (84.2%) of the recommendations were implemented. Structured scoring of MRIs provides a quantitative way to assess rates of agreement interpretation alongside how often management changes are recommended and implemented in a TB setting.

Improving palbociclib adherence among women with metastatic breast cancer using a CONnected CUstomized Treatment Platform: A pilot study.

OBJECTIVE: To pilot test a mobile health intervention using a CONnected CUstomized Treatment Platform that integrates a connected electronic adherence monitoring smartbox and an early warning system of non-adherence with bidirectional automated texting feature and provider alerts. METHODS: In total, 29 adult women with hormone-receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer and a prescription for palbociclib were asked to complete a survey and participate in a CONnected CUstomized Treatment Platform intervention, including use of a smartbox for real-time adherence monitoring, which triggered text message reminders for any missed or extra dose, and referrals to (a) participant's oncology provider after three missed doses or an episode of over-adherence, or (b) a financial navigation program for any cost-related missed dose. Use of smartbox, number of referrals, palbociclib adherence, CONnected CUstomized Treatment Platform usability measured by System Usability Scale, and changes in symptom burden and quality of life were assessed. RESULTS: Mean age was 57.6 and 69% were white. The smartbox was used by 72.4% of participants, with palbociclib adherence rate of 95.8%±7.6%. One participant was referred to oncology provider due to missed doses and one was referred to financial navigation. At baseline, 33.3% reported at least one adherence barrier including inconvenience to get prescription filled, forgetfulness, cost, and side effects. There were no changes in self-reported adherence, symptom burden or quality of life over 3 months. CONnected CUstomized Treatment Platform usability score was 61.9 ± 14.2. CONCLUSION: The CONnected CUstomized Treatment Platform interventions is feasible, resulting in a high palbociclib adherence rate without any decline in overtime. Future efforts should focus on improving usability.

Automated Registration and Color Labeling of Serial 3D Double Inversion Recovery MR Imaging for Detection of Lesion Progression in Multiple Sclerosis.

Automated co-registration and subtraction techniques have been shown to be useful in the assessment of longitudinal changes in multiple sclerosis (MS) lesion burden, but the majority depend on T2-fluid-attenuated inversion recovery sequences. We aimed to investigate the use of a novel automated temporal color complement imaging (CCI) map overlapped on 3D double inversion recovery (DIR), and to assess its diagnostic performance for detecting disease progression in patients with multiple sclerosis (MS) as compared to standard review of serial 3D DIR images. We developed a fully automated system that co-registers and compares baseline to follow-up 3D DIR images and outputs a pseudo-color RGB map in which red pixels indicate increased intensity values in the follow-up image (i.e., progression; new/enlarging lesion), blue-green pixels represent decreased intensity values (i.e., disappearing/shrinking lesion), and gray-scale pixels reflect unchanged intensity values. Three neuroradiologists blinded to clinical information independently reviewed each patient using standard DIR images alone and using CCI maps based on DIR images at two separate exams. Seventy-six follow-up examinations from 60 consecutive MS patients who underwent standard 3 T MR brain MS protocol that included 3D DIR were included. Median cohort age was 38.5 years, with 46 women, 59 relapsing-remitting type MS, and median follow-up interval of 250 days (interquartile range: 196-394 days). Lesion progression was detected in 67.1% of cases using CCI review versus 22.4% using standard review, with a total of 182 new or enlarged lesions using CCI review versus 28 using standard review. There was a statistically significant difference between the two methods in the rate of all progressive lesions (P < 0.001, McNemar's test) as well as cortical progressive lesions (P < 0.001). Automated CCI maps using co-registered serial 3D DIR, compared to standard review of 3D DIR alone, increased detection rate of MS lesion progression in patients undergoing clinical brain MRI exam.

Out-of-Pocket Expenditures for Imaging Examinations: Perspectives From National Patient Surveys Over Two Decades.

PURPOSE: Using national surveys, we longitudinally studied imaging costs-and specifically those paid out-of-pocket (OOP) by patients-over two decades. METHODS: Using 2000 to 2019 Medical Expenditure Panel Survey data, we identified all imaging-focused encounters (mammography, radiography, ultrasonography, and CT and MR [surveyed together in Medical Expenditure Panel Survey]) and calculated mean overall and OOP encounter costs. Effects of sociodemographic, personal, and clinical factors were measured using logistic regression and generalized linear modeling. RESULTS: We identified 102,717 patients (mean 45.6 years; 64.8% female; 58.8% White) undergoing 229,010 imaging-focused encounters. Between 2000 and 2019, mean costs of mammography, radiography, and ultrasonography increased 14.5%, 24.5%, and 40% and total mean cost of CT or MR decreased by 15.1%. OOP costs were incurred by 51%. Overall mean OOP costs increased 89.8% from 2000 to 2019. Mean OOP costs for mammography decreased by 32.9%; mean OOP costs for radiography, ultrasonography, and CT or MR increased 81%, 123.2%, and 61%, respectively. Patients were less likely to incur OOP costs when older, of racial and ethnic minorities, female, or recipients of public only (versus private) insurance. Among those with OOP costs, the presence of comorbidities, lack of insurance, younger age, and history of cancer significantly increased OOP costs. CONCLUSION: Mean overall patient OOP costs for imaging examinations increased significantly and substantially over the last two decades. Lack of insurance, younger age, history of cancer, and other comorbidities were associated with higher OOP costs. As diagnostic imaging utilization increases, patient financial hardship considerations merit further attention.