An exploration of financial toxicity among low-income patients with cancer in Central Texas: A mixed methods analysis.

OBJECTIVE: Financial toxicity is of increasing concern in the United States. The Comprehensive Score for Financial Toxicity (COST) is a validated measure; however, it has not been widely utilized among low-income patients and may not fully capture financial toxicity in this population. Furthermore, the relationships between financial toxicity, quality of life (QOL), and patient well-being are poorly understood. We describe the experience of financial toxicity among low-income adults receiving cancer care. We hypothesized that higher financial toxicity would be associated with less income and lower quality of life. Qualitative interviews focused on the financial impact of cancer treatment. METHOD: This study was conducted at a cancer clinic in Central Texas. Quantitative and qualitative data were collected in Fall and Spring 2018, respectively. The quantitative sample (N = 115) was dichotomized by annual income (<$15,000 vs. >$15,000). Outcomes included financial toxicity (COST), quality of life (FACT-G), and patient well-being (PROMIS measures: Anxiety, Depression, Fatigue, Pain Interference, and Physical Function). Associations between quality of life, patient well-being, and financial toxicity were evaluated using linear regression. Sequential qualitative interviews were conducted with a subsample of 12 participants. RESULTS: Patients with <$15k had significantly lower levels of QOL and patient well-being such as depression and anxiety compared to patients with >$15k across multiple measures. A multivariate linear regression found QOL (Β = 0.17, 95% CI = 0.05, 0.29, p = 0.008) and insurance status (Β = -3.79, 95% CI = -7.42, -0.16, p = 0.04), but not income, were significantly associated with financial toxicity. Three qualitative themes regarding patient's access to cancer care were identified: obtaining healthcare coverage, maintaining financial stability, and receiving social support. SIGNIFICANCE OF RESULTS: Low-income patients with cancer face unique access barriers and are at risk for forgoing treatment or increased symptom burdens. Comprehensive assessment and financial navigation may improve access to care, symptom management, and reduce strain on social support systems.

Wonders & Worries: A randomized clinical trial of a psychosocial intervention for children who have a parent with cancer.

OBJECTIVE: The aim of this study was to test the effectiveness of Wonders & Worries, a psychosocial intervention for children who have a parent with cancer. Primary goals were to improve family quality of life, functioning and communication skills as reported by parent and child, enhance children's emotional/behavioral adjustment and parenting efficacy, while decreasing parenting concerns and ill parents' depression and anxiety. METHODS: Sixty families were recruited from a community based non-profit agency. Parents diagnosed with Stage I-III cancer and their children ages 5-14 years were enrolled and randomized into intervention (n = 32) or wait-list control groups (n = 28). Families received 2 parent consults, six weekly 1-h individual child sessions, and 1 treatment center tour. The intervention was comprised of an age-appropriate understanding of cancer and expression of feelings, coping skills to ease feelings related to parent's cancer and enhanced ability to communicate about the disease. Controls received parent consult and access to W & W resources. Data were obtained from standardized measures at baseline; 6 and 10 weeks follow up. RESULTS: Intervention group significantly improved on parenting concerns, parenting self-efficacy, and family quality of life. Children in the intervention group had significantly lower emotional and behavioral problems and worries related to cancer compared to controls. The intervention failed to significantly affect ill parent's anxiety, depressed mood, family functioning and child's anxiety. CONCLUSIONS: The Wonders & Worries intervention promoted positive adaptation for ill parents and their children. This intervention is promising enough to warrant further refinement and testing with larger, more diverse samples.

Patient reported outcomes affecting quality of life in socioeconomically disadvantaged cancer patients.

PURPOSE: The aim of this study was to identify correlates of quality of life (QOL) for socioeconomically disadvantaged cancer patients receiving care in the "safety net" health system. DESIGN: This cross-sectional study used linear regressions to determine the effect of patient reported outcome measures (PRO) on QOL.Sample/Methods: Cancer patients (n = 115) receiving drug therapy completed a series of PROs including: Functional Assessment of Cancer Therapy (FACT-G), PROMIS (Anxiety, Depression, Fatigue, Pain Interference, and Physical Function), and the Comprehensive Score for Financial Toxicity. FINDINGS: More than 60% of patients reported an annual income below $24,999. Forty-five percent of patients were either uninsured or county-funded. Depression, pain, and financial toxicity were found to be consistently significant correlates of QOL.Implications: Cancer patients with existing financial strain have unique psychosocial stressors. This study provides insight into the relationship between these stressors, and the need for targeted screening and intervention that address such aspects of care.

House Dust Mite Related Allergic Rhinitis and REM Sleep Disturbances.

PURPOSE: Sleep disturbances are common in patients with allergic rhinitis (AR). Perennial allergens like house dust mites (HDM) are difficult to avoid and have nocturnal impacts on the respiratory system and Quality of Life (QOL). The Rapid Eye Movement (REM) sleep stage is associated with memory, cognition, dreams, and overall restfulness, which can be impaired in AR patients with Sleep Disordered Breathing (SDB) even when normal all-night apnea-hypopnea (AHI) or respiratory disturbance (RDI) indices are noted on polysomnography (PSG). We hypothesized that AR HDM allergen positive patients would show REM-specific SDB reflected in their objectively elevated REM-RDI values. MATERIALS AND METHODS: This retrospective analysis of 100 patients included 47 with HDM positive allergy testing. All patients underwent PSG testing calculating the RDI during REM. Multivariate logistic regression models evaluated relationships between allergic statuses and sleep parameters while controlling for potential confounders. RESULTS: Compared with allergy negative patients, HDM allergen positive patients were significantly more likely (OR 4.29, 95%CI 1.26-14.62) to have a REM-RDI in the moderate/severe range (≥15 events/h). CONCLUSIONS: Our study highlighted the significance of respiratory allergies to HDM in patients with SDB. We revealed a significant relationship between HDM allergen positivity and SDB characterized by elevated REM-RDI regardless of all-night AHI, RDI, or REM-AHI values. Clinical implications of knowing about disturbed REM and/or HDM allergenicity include better preparation, treatment, outcomes, and QOL for allergic, SDB, and upper airway surgery patients.

Clinical associations between allergies and rapid eye movement sleep disturbances.

BACKGROUND: Allergic rhinitis, an immunoglobulin E inflammatory condition including nasal congestion, obstruction, sneezing, pruritus, and fatigue symptoms, has significant impact on quality of life and impairs sleep. Sleep-disordered breathing (SDB) patients often have normal all-night apnea-hypopnea (AHI) or respiratory-disturbance (RDI) indices on polysomnography (PSG). We hypothesized that the rapid eye motion-respiratory disturbance index (REM-RDI) may be a novel predictor of allergic status. METHODS: A retrospective analysis of 100 patients compared REM-RDI results in 67 allergen-positive patients with 33 nonallergic patients who presented with nasal blockage. Subjects completed STOP-Bang©, 22-item Sino-Nasal Outcome Test (SNOT-22)©, and Epworth Sleepiness Scale© questionnaires and underwent skin-prick testing (SPT) and PSGs including REM-RDI values. Using multivariate logistic regression models, we evaluated relationships between allergic status and sleep parameters while controlling for possible confounders including body mass index (BMI). RESULTS: Using REM-RDI as the outcome of interest, allergen-positive patients were 3.92 times more likely to have REM-RDI values in a moderate/severe range (≥15 events/hour); and patients with moderate/severe REM-RDI values were more likely to be allergen positive (p < 0.05). Allergic status was not significantly related to all-night AHI, RDI, or REM-AHI. BMI was not significantly related to REM-RDI. STOP-Bang© was related to allergy status (p = 0.02) and REM-RDI (p < 0.01). Allergic patients had increased REM latency and less total amount of REM. CONCLUSION: We revealed significant bidirectional associations between allergen positivity and increased REM-RDI values independent of BMI, AHI, RDI, and REM-AHI. Allergic inflammation and REM-RDI data may play important roles in diagnosing and treating fatigued SDB patients and as objective perioperative safety and outcomes measures.

Wonders & Worries: evaluation of a child centered psychosocial intervention for families who have a parent/primary caregiver with cancer.

OBJECTIVE: Scant evidence exists to guide interventions for children who have a parent with cancer. This study evaluated the outcomes of a community based psychosocial intervention targeted to children dealing with parental or primary caregiver cancer. This curriculum provided an age-appropriate understanding of the illness, facilitated the expression of feelings, identified individual coping skills to help ease feelings related to parent's cancer, and enhanced the family's ability to communicate about the disease. METHODS: Families whose children participated in the six-week curriculum-based intervention completed a questionnaire that included demographic information, a five-item assessment of changes in parenting abilities, and a nine-item assessment of changes in children's behavioral issues. The prevalence of each reported item was determined through a secondary analyses of cross-sectional data derived from a multi-year sample of these survey results. RESULTS: A sample of 156 families responded to the survey between 2009 and 2014. A majority of families described improvement in all five areas of parenting abilities assessed including communication skills and confidence in parenting. Amelioration of multiple children's issues was reported including improved communication skills (87%), reduced anxiety (84%), increased feeling of security at home (90%), and improved school performance (73%). CONCLUSIONS: The results reported here suggest that this child centered psychosocial intervention promoted positive adaptation by actively supporting families and children while a parent/primary caregiver coped with a cancer diagnosis. Future research is planned utilizing a randomized controlled study design to formally evaluate the effectiveness and preventative impact of this manualized six-week curriculum. Copyright © 2016 John Wiley & Sons, Ltd.

The Community Diabetes Education (CoDE) program: cost-effectiveness and health outcomes.

BACKGROUND: Limited evidence exists regarding the long-term effects of community health worker-led diabetes management programs on health outcomes and cost-effectiveness, particularly in low-income, ethnic minority populations. PURPOSE: To examine the long-term cost-effectiveness and improvements in diabetes-related complications of a diabetes education and management intervention led by community health workers among uninsured Mexican Americans. METHODS: Clinical data, changes in hemoglobin A1c over 12 months, and costs from an RCT of 180 uninsured Mexican Americans with type 2 diabetes conducted in 2006 were utilized for secondary analyses in 2012. Simulation modeling was used to estimate long-term cost and health outcomes using the validated Archimedes Model. The absolute differences for the incremental cost-effectiveness ratios and cumulative incidence of diabetes-related complications were derived by comparing intervention and control groups. RESULTS: During a 20-year time horizon, participants who received the intervention would be expected to have significantly lower hemoglobin A1c levels (p<0.001), fewer foot ulcers (p<0.001), and a reduced number of foot amputations (p=0.005) in comparison with a control group receiving usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life year gained was estimated for intervention participants during the same time period. CONCLUSIONS: A simulated clinical trial suggests that a community health worker-led diabetes intervention is a cost-effective way to reduce diabetes-related complications for uninsured Mexican Americans during a 20-year horizon in comparison to usual medical care.

Evaluation of quality improvement performance in the Community Diabetes Education (CoDE) program for uninsured Mexican Americans: results of a randomized controlled trial.

The objective of this article is to quantify quality improvement using data from a randomized controlled trial that tested the effectiveness of a community health worker in the primary role of diabetes educator in a clinic serving uninsured Mexican Americans. The intervention group received 7 hours of diabetes education/case management in excess of usual medical care. Of 16 process and outcome measures evaluated, the intervention group was significantly more likely to have received a dilated retinal examination, and 53% achieved a hemoglobin A1c below 7% compared with 38% of the control group participants. Composite quality measures were similar in magnitude with published practice-based benchmarks at study conclusion. This suggests that the overall diabetes care delivered in this clinic serving uninsured patients was comparable to the levels of excellence achieved in other primary care settings. Quantitative measurements of quality improvement can inform health policy regarding the relative effectiveness of diabetes interventions.

Community Diabetes Education (CoDE) for uninsured Mexican Americans: a randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker.

AIMS: The purpose of this randomized controlled trial was to determine the impact of a culturally tailored diabetes education program led by a community health worker (CHW) on the HbA1c, blood pressure, body mass index (BMI) and lipid status of uninsured Mexican Americans with diabetes. METHODS: Adult patients were recruited from a community clinic and randomized into intervention (n=90) and control (n=90) groups. Both groups received usual medical care from clinic physicians. The intervention group participated in the Community Diabetes Education (CoDE) program over 12 months. The primary outcome of interest was HbA1c. Secondary outcomes included blood pressure, BMI and lipid status. Variations in outcomes over time were assessed within groups and between groups using linear mixed-models and an intention-to-treat approach. Assessment of changes in HbA1c, blood pressure and lipid status over 12 months included variables to control for modifications made to antidiabetic, antihypertensive and lipid lowering medications. RESULTS: There was no difference in baseline characteristics between the intervention and control groups. Mean changes of HbA1c over 12 months showed a significant intervention effect (-.7%, p=.02) in the CoDE group compared with controls. HbA1c decreased significantly from baseline to 12 months within the intervention (-1.6%, p<.001) and control (-.9%, p<.001) groups. No differences between groups for secondary outcomes were found. CONCLUSIONS: This study supports the effectiveness of CHWs as diabetes educators/case managers functioning as integral members of the health care team in community clinic settings serving uninsured Mexican Americans.

Hospital board infrastructure and functions: the role of governance in financial performance.

Increased stake of boards in the leadership of the hospitals makes them play a significant role in the financial health of their institutions. Understanding of the correct approach to successfully fulfill this purpose is critical for preparing their organizations for positioning adequately in the health care market. Governmental agencies and public companies, including insurers, will be interested in the extent to which hospital boards have adopted the provisions of accounting reform laws like those introduced by the Sarbanes-Oxley Act. It will remain for the boards to balance their oversight role for financial performance with the pressures of financial accountability.

Effectiveness of a community health worker as sole diabetes educator: comparison of CoDE with similar culturally appropriate interventions.

The feasibility of a newly designed Community Diabetes Education (CoDE) intervention was evaluated in preparation for the development of a pilot study of this program. A comparison between CoDE and similar culturally appropriate diabetes management programs developed specifically for Hispanic Americans demonstrates its unique features. Patient insurance status, duration of the intervention, delivery in individual and/or group settings, the characteristics of the diabetes educator(s), the other professional resources involved in these interventions, the associated costs, and the reported health outcomes were used in the comparison. The significant improvement in hemoglobin A1c observed in patients who completed one year of CoDE suggests that a community health worker can serve as the primary patient educator in the absence of more highly educated personnel required by American Diabetes Association-certified diabetes education programs. This low-cost model can be reproduced de novo in community health centers or inserted into existing diabetes management interventions.

CoDE: Community Diabetes Education for uninsured Mexican Americans.

Low-cost diabetes education programs that target Mexican Americans are essential to reduce the observed health disparities in this population. A culturally appropriate intervention was developed as the centerpiece of the Community Diabetes Education (CoDE) program. This article describes the structure, patient acceptance, and costs of this one-to-one educational model delivered in 7 patient contact hours by a community health worker over 12 months in a community clinic serving the uninsured. A total of 162 patients-predominantly female, Spanish-speaking Mexican American patients with type 2 diabetes of mean duration of 6.5 years-enrolled in the program, and a dropout rate of 22% was observed during the 12-month period. Preliminary analysis indicated that program capacity was 120 patients per month, and the annual direct medical expenditure per CoDE participant was $461. The hemoglobin A(1c) was significantly reduced in patients who participated in the program for 12 months. Sustainable, low-cost, community-based programs like CoDE and long-term patient participation will help reduce the burden of diabetes in the underserved Hispanic population.