Determinants of Patient-Centered Financial Stress in Patients With Locally Advanced Head and Neck Cancer

Purpose To prospectively estimate patient-centered financial stress and its relationship with health care utilization in patients with head and neck cancer. This was a survey-based, longitudinal, prospective study of treatment-naive patients with stage III, IVa, or IVb locally advanced head and neck cancer at a single-institution tertiary care hospital fromMay2013 to November 2014. With 121 patients approached, 73 (60%) agreed to participate. Methods Self-reported data were collected on demographics, income, wealth, cost-coping strategies, out-of-pocket costs, supportive medication compliance, and perceived social isolation. Health care utilization was measured by hospital admissions and outpatient appointments on a 6-month timeline. Logistic regression models were constructed to identify factors associated with use of cost-coping strategies. Covariates included all demographics, measures of income, wealth, out-of-pocket costs, indirect costs, and perceived social isolation. Results Fifty-one patients (69%) relied on at least one coping strategy. On multivariable analysis, Medicaid patients were more likely than privately insured patients to use cost-coping strategies ( odds ratio, 42.3; P =.0042). Decreased wealth ( P =.002) and higher total out-ofpocket costs (P =.003) were independently associated with using cost-coping strategies. Patients with high perceived social isolation were also more likely to use cost-coping strategies (odds ratio, 11.5; P=. 01). Patients with high perceived social isolationweremore likely to report nonadherence to supportive medications (21.4 v 5.45 days over 6 months; P =.0278) and missed appointments (seven v three; P =.0077). Conclusion A majority of patients used at least one cost-coping strategy during their treatment, highlighting the financial stress that patients experience. Perceived social isolation is an important social determinant of increased medication nonadherence, missed appointments, and use of cost-coping strategies. Interventions should be investigated in at-risk patients who may suffer from financial stress.