Historical Redlining, Socioeconomic Distress, and Risk of Heart Failure Among Medicare Beneficiaries.

BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P<0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P=0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (Pinteraction<0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P=0.02). CONCLUSIONS: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities.

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.

Financial burden following adult liver transplantation is common and associated with adverse recipient outcomes.

The financial impact of liver transplantation has been underexplored. We aimed to identify associations between high financial burden (≥10% annual income spent on out-of-pocket medical costs) and work productivity, financial distress (coping behaviors in response to the financial burden), and financial toxicity (health-related quality of life, HRQOL) among adult recipients of liver transplant. Between June 2021 and May 2022, we surveyed 207 adult recipients of liver transplant across 5 US transplant centers. Financial burden and distress were measured by 25 items adapted from national surveys of cancer survivors. Participants also completed the Work Productivity and Activity Impairment and EQ-5D-5L HRQOL questionnaires. In total, 23% of recipients reported high financial burden which was significantly associated with higher daily activity impairment (32.9% vs. 23.3%, p =0.048). In adjusted analyses, the high financial burden was significantly and independently associated with delayed or foregone medical care (adjusted odds ratio, 3.95; 95% CI, 1.85-8.42) and being unable to afford basic necessities (adjusted odds ratio, 5.12; 95% CI: 1.61-16.37). Recipients experiencing high financial burden had significantly lower self-reported HRQOL as measured by the EQ-5D-5L compared to recipients with low financial burden (67.8 vs. 76.1, p =0.008) and an age-matched and sex-matched US general population (67.8 vs. 79.1, p <0.001). In this multicenter cohort study, nearly 1 in 4 adult recipients of liver transplant experienced a high financial burden, which was significantly associated with delayed or foregone medical care and lower self-reported HRQOL. These findings underscore the need to evaluate and address the financial burden in this population before and after transplantation.

Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With and Without Food Insecurity.

BACKGROUND: Compared to traditional Medicare (TM), Medicare Advantage (MA) plans impose out-of-pocket cost limits and offer extra benefits, potentially providing financial relief for MA enrollees, especially for those with food insecurity. OBJECTIVE: To examine whether the prevalence of food insecurity differs between TM and MA enrollees at baseline and then examine whether MA enrollment in a baseline year is associated with less financial hardships in the following year, relative to TM enrollment, especially for those experiencing food insecurity. DESIGN: We conducted a retrospective longitudinal cohort study. PARTICIPANTS: Our analysis included 2807 Medicare beneficiaries (weighted sample size, 23,963,947) who maintained continuous enrollment in either TM or MA in both 2020 and 2021 from the Medical Expenditure Panel Survey. MAIN MEASURES: We assessed outcomes related to financial hardships in health care and non-health care domains (measured in 2021). Our primary independent variables were food insecurity and MA enrollment (measured in 2020). RESULTS: The point estimate of food insecurity prevalence was greater among MA enrollees than TM enrollees, but the difference was not statistically significant (1.1 percentage points [95% CI, - 1.0, 3.4]). Furthermore, there is evidence that compared to TM enrollment, MA enrollment did not mitigate the risk of financial hardship, particularly for food-insecure enrollees. Rather, food-secure MA enrollees faced greater financial hardship in the following year than food-secure TM enrollees (11.2% [8.9-13.6] and 7.6% [6.9-8.3] for problems paying medical bills and 5.5% [4.6-6.4] and 2.8% [2.1-3.6] for paying medical bills over time). Moreover, the point estimate of financial hardship was higher among food-insecure MA enrollees than food-insecure TM enrollees (21.5% [5.4-37.5] and 11.2% [4.1-18.4] and 23.7% [9.6-37.9] and 6.9% [0.5-13.3]) despite the lack of statistical significance. CONCLUSION: These findings suggest that the promise of financial protection offered by MA plans has not been fully realized, particularly for those with food insecurity.

Financial toxicity among patients undergoing resectional surgery for inflammatory bowel disease in the United States.

AIM: Financial toxicity describes the financial burden and distress that patients experience due to medical treatment. Financial toxicity has yet to be characterized among patients with inflammatory bowel disease (IBD) undergoing surgical management of their disease. This study investigated the risk of financial toxicity associated with undergoing surgery for IBD. METHODS: This study used a retrospective analysis using the National Inpatient Sample from 2015 to 2019. Adult patients who underwent IBD-related surgery were identified using the International Classification of Diseases (10th Revision) diagnostic and procedure codes and stratified into privately insured and uninsured groups. The primary outcome was risk of financial toxicity, defined as hospital admission charges that constituted 40% or more of patient's post-subsistence income. Secondary outcomes included total hospital admission cost and predictors of financial toxicity. RESULTS: The analytical cohort consisted of 6412 privately insured and 3694 uninsured patients. Overall median hospital charges were $21 628 (interquartile range $14 758-$35 386). Risk of financial toxicity was 86.5% among uninsured patients and 0% among insured patients. Predictors of financial toxicity included emergency admission, being in the lowest residential income quartile and having ulcerative colitis (compared to Crohn's disease). Additional predictors were being of Black race or male sex. CONCLUSION: Financial toxicity is a serious consequence of IBD-related surgery among uninsured patients. Given the pervasive nature of this consequence, future steps to support uninsured patients receiving surgery, in particular emergency surgery, related to their IBD are needed to protect this group from financial risk.

Mental Health Among Puerto Rican Adolescents Living in the United States During the COVID-19 Pandemic.

OBJECTIVES: The present study examined how different family level (family financial stress, family violence) and individual (food insecurity, gender, race) determinants of health were associated with mental health among Puerto Rican adolescents living in the U.S. during the COVID-19 pandemic. METHOD: A sample consisting of 119 Puerto Rican adolescents, aged 13 to 17, was collected via Qualtrics Panels between November 2020 and January 2021. We examined the association between family financial stress experienced during the pandemic and psychological distress. We also evaluated whether the association between family financial stress and psychological distress was moderated by family violence, food insecurity, and the participant's gender and race. RESULTS: Findings showed that food insecurity positively predicted psychological distress. Results also showed that participants' race moderated the association between family financial stress and psychological distress. Specifically, we found that while there was a significant positive association between family financial stress and psychological distress among Puerto Rican adolescents who identified as a racial minority, this association was nonsignificant among White Puerto Rican adolescents. CONCLUSION: Our research highlights the significant role of COVID-19 related family financial stress and food insecurity on Puerto Rican adolescents' poor mental health during the COVID-19 pandemic.

Income loss and subsequent poor psychological well-being among the Chinese population during the early COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has had major ramifications for health and the economy at both the individual and collective levels. This study examined exogenous negative changes in household income and their implications on psychological well-being (PWB) among the Chinese population during the COVID-19 pandemic. METHODS: Data were drawn from the early China COVID-19 Survey, a cross-sectional anonymous online survey administered to the general population in China. Self-reported PWB was measured using a 5-point Likert scale with five questions related to the participants' recent psychological state. Hierarchical multiple linear regression was employed to examine whether income loss during the COVID-19 pandemic was associated with poor psychological health. RESULTS: This study included 8,428 adults, of which 90% had suffered from a moderate or severe loss of household income due to the early COVID-19 pandemic. Those who had experienced moderate or severe loss of income scored significantly lower on psychological well-being than those who did not experience income loss (19.96 or 18.07 vs. 21.46; P < 0.001); after controlling for confounders, income loss was negatively associated with PWB scores (moderate income loss: B = - 0.603, P < 0.001; severe income loss: B = - 1.261, P < 0.001). An interaction effect existed between the degree of income loss and pre-pandemic income groups. Specifically, participants in the middle-income group who had suffered severe income loss scored the lowest on PWB (B = - 1.529, P < 0.001). There was also a main effect on income loss, such that participants with varying degrees of income loss differed across five dimensions, including anhedonia, sleep problems, irritability or anger, difficulty with concentration, and repeated disturbing dreams related to COVID-19. CONCLUSIONS: Income loss during the pandemic has had detrimental consequences on psychological well-being, and the magnitude of the impact of income loss on psychological well-being varied according to previous income levels. Future policy efforts should be directed toward improving the psychological well-being of the economically vulnerable and helping them recover from lost income in the shortest time possible.

Family economic pressure and early adolescents' prosocial behavior: The importance of considering the types of prosocial behavior.

BACKGROUND: Prior research findings are mixed regarding whether prosocial behavior is positively or negatively related to socioeconomic status and its correlates, such as economic pressure. This may be due to the lack of considerations for the type of prosocial behavior. AIMS: In this study, we aimed to examine how six types of prosocial behavior (i.e., public, anonymous, compliant, emotional, dire, and altruistic) are related to economic pressure among early adolescents. We hypothesized that family economic pressure would be associated with each type of prosocial behavior in differing ways. MATERIALS & METHODS: Participants were 11-14 years old (N = 143, Mage = 12.2 years, SDage = 0.87, 63 boys, 1 trans-identified boy, 55 girls), early adolescents and their parents. Among them, 54.6% were non-Hispanic/Latinx (NH/L) White, 23.8% were NH/L Black, 11.2% were NH/L Asian, 2.1% were NH/L Multiracial, and 8.4% were Hispanic/Latinx. Parents reported family economic pressure and adolescents' six types of prosocial behavior. RESULTS: Path analysis revealed that economic pressure was negatively associated with emotional and dire prosocial behavior over and above age, gender, and race/ethnicity. Family economic pressure was unrelated to public, anonymous, compliant, and altruistic prosocial behavior. DISCUSSION: These findings show some support for the Family Stress Model, such that economic stress might hinder youth's prosocial development. At the same time, youth may have similar levels of certain types of prosocial behavior regardless of their family's economic pressure. CONCLUSION: This research provided insight into the complex relation between economic pressure and youth's prosocial behavior which varies depending on the type of behavior.

Financial burden, distress, and toxicity in cardiovascular disease.

Cardiovascular disease (CVD) is a major source of financial burden and distress, which has 3 main domains: (1) psychological distress; (2) cost-related care non-adherence or medical care deferral, and (3) tradeoffs with basic non-medical needs. We propose 4 ways to reduce financial distress in CVD: (1) policymakers can expand insurance coverage and curtail underinsurance; (2) health systems can limit expenditure on low-benefit, high-cost treatments while developing services for high-risk individuals; (3) physicians can engage in shared-decision-making for high-cost interventions, and (4) community-based initiatives can support patients with system navigation and financial coping. Avenues for research include (1) analysis of how healthcare policies affect financial burden; (2) comparative effectiveness studies examining high and low-cost strategies for CVD management; and (3) studying interventions to reduce financial burden, financial coaching, and community health worker integration.

Healthcare utilization and economic burden of difficult-to-treat rheumatoid arthritis: a cost-of-illness study.

OBJECTIVES: To determine the impact of difficult-to-treat rheumatoid arthritis (D2T RA) on (costs related to) healthcare utilization, other resource use and work productivity. METHODS: Data regarding healthcare utilization, other resource use and work productivity of 52 D2T (according to the EULAR definition) and 100 non-D2T RA patients were collected via a questionnaire and an electronic patient record review during a study visit. Annual costs were calculated and compared between groups. Multivariable linear regression analysis was performed to assess whether having D2T RA was associated with higher costs. RESULTS: Mean (95% CI) annual total costs were €37 605 (€27 689 - €50 378) for D2T and €19 217 (€15 647 - €22 945) for non-D2T RA patients (P<0.001). D2T RA patients visited their rheumatologist more frequently, were more often admitted to day-care facilities, underwent more laboratory tests and used more drugs (specifically targeted synthetic DMARDs), compared with non-D2T RA patients (P<0.01). In D2T RA patients, the main contributors to total costs were informal help of family and friends (28%), drugs (26%) and loss of work productivity (16%). After adjustment for physical functioning (HAQ), having D2T RA was no longer statistically significantly associated with higher total costs. HAQ was the only independent determinant of higher costs in multivariable analysis. CONCLUSIONS: The economic burden of D2T RA is significantly higher than that of non-D2T RA, indicated by higher healthcare utilization and higher annual total costs. Functional disability is a key determinant of higher costs in RA.

Economic burden of central nervous system metastases in human epidermal growth factor receptor 2-positive breast cancer.

Aim: Compare healthcare resource utilization and costs among patients with HER2+ metastatic breast cancer (MBC) with and without central nervous system (CNS) metastases. Methods: Retrospective matched cohort study using IQVIA's PharMetrics® Plus claims database. Results: Patients with CNS metastases (n = 753) experienced more outpatient, emergency room and inpatient visits versus controls (n = 753; all p < 0.05). In the post-index year, median total all-cause healthcare costs were significantly higher among patients with CNS metastases versus controls ($112,402 vs $50,835; p < 0.0001); outpatient costs primarily drove the cost differential. Conclusion: More effective therapies are needed that improve clinical outcomes and reduce economic burden associated with CNS metastases in patients with HER2+ MBC.

The CASSIOPEA Study (Economic Crisis and Adherence to the Mediterranean diet: poSSIble impact on biOmarkers of inflammation and metabolic PhEnotypes in the cohort of the Moli-sAni Study): Rationale, design and characteristics of participants.

BACKGROUND AND AIMS: The CASSIOPEA Study was designed to evaluate whether the economic downturn during the late 2000s was a contributing factor to the observed decrease in adherence to Mediterranean diet (MD). METHODS AND RESULTS: The study protocol consists of two steps: A) recall of 7406 men and women who, between 2005 and 2006, had been randomly recruited in the Moli-sani Study from the general population of Molise, to assess possible economic hardship (EH) related to the economic crisis initiated in 2007; B) re-examination, between 2017 and 2020, of available subjects identified in Step 1 as poorly or harder hit by EH to test the hypothesis that EH is associated with a decrease in MD adherence, possibly resulting in increased inflammation. The results of Step 1 are reported here. From the initial sample of individuals re-examined after 12.6 years (median; IQR = 12.1-13.0 y), 3646 were finally analysed. An Economic Hardship Score (EHS; range 0-14) was obtained by scoring three domains: 1) change in employment status; 2) financial hardship and 3) financial hardship for health expenditures. Overall, 37.8% of the sample reported high EHS (≥3), whilst 32% scored 0 (no EH). Those with high EHS were prevalently women and younger, with low socioeconomic status. CONCLUSIONS: High economic hardship was prevalently reported by weaker socioeconomic groups. Longitudinal analysis (step 2) will examine whether the economic crisis had an effect on adherence to Mediterranean diet with consequent potential impact on inflammation, one of the main biological pathways linking MD to health outcomes. CLINICALTRIALS. GOV IDENTIFIER: NCT03119142.

Prevalence, trends, and demographic characteristics associated with self-reported financial stress among head and neck cancer patients in the United States of America.

BACKGROUND: Understanding the economic burden imposed by head and neck cancer diagnoses essential to contextualize healthcare decision-making for these patients. METHODS: A retrospective, cross-sectional analysis of the US National Health Interview Survey was performed between 2013 and 2018. Demographic and socioeconomic characteristics of adult head and neck cancer patients were analyzed in relation to survey responses related to financial stress factors. RESULTS: Among 710 head and neck cancer patients, 21.39% (95% Cl, 17.69%-25.09%) reported difficulty paying medical bills within the previous 12 months. Multivariable logistic regression revealed insurance status [aOR 2.17 (95% CI, 1.15-4.07), p < 0.001] and poverty status [aOR 2.55 (95% CI, 1.48-4.37), p = 0.017] to be significantly associated with difficulty paying medical bills. CONCLUSION: A large proportion of HNC patients may experience financial stress related not only to out-of-pocket health care costs, but also exogenous financial challenges. These findings suggest that a significant proportion of HNC patients may experience financial stress related not only to out-of-pocket health care costs, but also exogenous financial challenges. Such barriers may impede patients' ability to access and adhere to treatment or force detrimental tradeoffs between health care and other essential needs.

Financial Strain and Suicide Attempts in a Nationally Representative Sample of US Adults.

Although research has identified many suicide risk factors, the relationship between financial strain and suicide has received less attention. Using data representative of the US adult population (n = 34,653) from wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions, we investigated the association between financial strain-financial debt/crisis, unemployment, past homelessness, and lower income-and subsequent suicide attempts and suicidal ideation. Multivariable logistic regression controlling for demographic and clinical covariates showed that cumulative financial strain was predictive of suicide attempts between waves 1 and 2 (odds ratio (OR) = 1.53, 95% confidence interval (CI): 1.32, 1.77). Wave 1 financial debt/crisis (OR = 1.58, 95% CI: 1.06, 2.34), unemployment (OR = 1.52, 95% CI: 1.10, 2.10), past homelessness (OR = 1.50, 95% CI: 1.03, 2.17), and lower income (OR = 1.51, 95% CI: 1.01, 2.25) were each associated with subsequent suicide attempts. Respondents endorsing these 4 financial-strain variables had 20 times higher predicted probability of attempting suicide compared with respondents endorsing none of these variables. Analyses yielded similar results examining suicidal ideation. Financial strain accumulated from multiple sources (debt, housing instability, unemployment, and low income) should be considered for optimal assessment, management, and prevention of suicide.

Measuring financial toxicity incurred after treatment of head and neck cancer: Development and validation of the Financial Index of Toxicity questionnaire.

BACKGROUND: The treatment of head and neck cancer (HNC) may cause significant financial toxicity to patients. Herein, the authors have presented the development and validation of the Financial Index of Toxicity (FIT) instrument. METHODS: Items were generated using literature review and were based on expert opinion. In item reduction, items with factor loadings of a magnitude <0.3 in exploratory factor analysis and inverse correlations (r < 0) in test-retest analysis were eliminated. Retained items constituted the FIT. Reliability tests included internal consistency (Cronbach α) and test-retest reliability (intraclass correlation). Validity was tested using the Spearman rho by comparing FIT scores with baseline income, posttreatment lost income, and the Financial Concerns subscale of the Social Difficulties Inventory. Responsiveness analysis compared change in income and change in FIT between 12 and 24 months. RESULTS: A total of 14 items were generated and subsequently reduced to 9 items comprising 3 domains identified on exploratory factor analysis: financial stress, financial strain, and lost productivity. The FIT was administered to 430 patients with HNC at 12 to 24 months after treatment. Internal consistency was good (α = .77). Test-retest reliability was satisfactory (intraclass correlation, 0.70). Concurrent validation demonstrated mild to strong correlations between the FIT and Social Difficulties Inventory Money Matters subscale (Spearman rho, 0.26-0.61; P < .05). FIT scores were found to be inversely correlated with baseline household income (Spearman rho, -0.34; P < .001) and positively correlated with lost income (Spearman rho, 0.24; P < .001). Change in income was negatively correlated with change in FIT over time (Spearman rho, -0.25; P = .04). CONCLUSIONS: The 9-item FIT demonstrated internal and test-retest reliability as well as concurrent and construct validity. Prospective testing in patients with HNC who were treated at other facilities is needed to further establish its responsiveness and generalizability.

Financial hardship in Chinese cancer survivors.

BACKGROUND: The purpose of this study was to estimate the proportion of Chinese cancer survivors experiencing financial hardship and then examine the relationship between material and behavioral financial hardship. METHODS: This study surveyed 964 cancer survivors who were 30 to 64 years old and 644 survivors who were 65 years old or older during 2015-2016 (1608 survivors in all). Material financial hardship was measured by whether they had borrowed money because of cancer, its treatment, or the lasting effects of treatment, and behavioral financial hardship was measured by whether they had forgone some cancer-related medical care because of cost. Multivariable logistic regression models were used to examine factors associated with material financial hardship by age group. RESULTS: Approximately 44% of the cancer survivors who were 65 years old or older borrowed money or went into debt because of cancer, and 54% of younger patients (P < .01) reported cancer-related debts. Among these survivors with cancer care debt, survivors aged 65 years old or older had a lower proportion of borrowing more than 50,000 Chinese yuan (CNY; approximately US $7700) than survivors aged 30 to 64 years (14% vs 20%). In both age groups, approximately 10% of cancer survivors reported that they had experienced behavioral financial hardship. After adjustments for covariates, cancer survivors who reported material financial problems were more likely to report behavioral financial hardship (odds ratio [OR] for those aged 30-64 years, 3.72; 95% confidence interval [CI], 2.13-6.50; OR for those aged 65 years or older, 5.48; 95% CI, 2.69-11.15). CONCLUSIONS: Older cancer survivors in China experience significant material financial hardship, but it is not as noticeable as younger patients' hardship. The results highlight the importance of identifying cancer survivors who are more likely to experience financial hardship and improving the affordability of cancer care in China.

Financial Hardship After Traumatic Injury: Risk Factors and Drivers of Out-of-Pocket Health Expenses.

BACKGROUND: Trauma-related disorders rank among the top five most costly medical conditions to the health care system. However, the impact of out-of-pocket (OOP) health expenses for traumatic conditions is not known. In this cross-sectional study, we use nationally representative data to investigate whether patients with a traumatic injury experienced financial hardship from OOP health expenses. METHODS: Using data from the Medical Expenditure Panel Survey from 2010 to 2015, we analyzed the financial burden associated with a traumatic injury. Primary outcomes were excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income). A multivariable logistic regression analysis evaluated whether these outcomes were associated with traumatic injury, adjusting for demographic, socioeconomic, and health care factors. We then completed a descriptive analysis to elucidate drivers of total OOP expenses. RESULTS: Of the 90,964 families in the cohort, 6434 families had a traumatic injury requiring a visit to the emergency room and 668 families had a traumatic injury requiring hospitalization. Overall 1 in 8 households with an injured family member requiring hospitalization experienced financial hardship. These families were more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). The largest burden of OOP expenses was due to prescription drug costs, with inpatient costs as a major driver of OOP expenses for those requiring hospitalization. CONCLUSIONS: Households with an injured family member requiring hospitalization are significantly more vulnerable to financial hardship from OOP health expenses than the noninjured population. Prescription drug and inpatient costs were the most significant drivers of OOP health expenses.

A theoretical model of financial burden after cancer diagnosis.

Current models of financial burden after cancer do not adequately define types of financial burden, moderators or causes. We propose a new theoretical model to address these gaps. This model delineates the components of financial burden as material and psychological as well as healthcare-specific (affording treatment) versus general (affording necessities). Psychological financial burden is further divided into worry about future costs and rumination about past and current financial burden. The model hypothesizes costs and employment changes as causes, and moderators include precancer socioeconomic status and post-diagnosis factors. The model outlines outcomes affected by financial burden, including depression and mortality. Theoretically derived measures of financial burden, interventions and policy changes to address the causes of financial burden in cancer are needed.