Dr. Shannon Westin, Dr. Stephanie Wheeler, and Dr. Caitlin Biddell discuss the paper "Economic Evaluation of a Non-Medical Financial Assistance Program on Missed Treatment Appointments Among Adults With Cancer," a simultaneous publication, podcast, and presentation at the ASCO Quality Care Symposium.

TRANSCRIPT

The guest on this podcast episode has no disclosures to declare.

Dr. Shannon Westin: Hello, everyone, and welcome to another episode of JCO After Hours, the podcast where we get in-depth on manuscripts published in the Journal of Clinical Oncology. I'm your host, Shannon Westin, Social Media Editor of the JCO and GYN Oncologist. And I am so excited that today we have a simultaneous publication in JCO and presentation at the 2023 ASCO Quality Care Symposium here on 10/28/2023. And this is going to be the manuscript “Economic Evaluation of a Nonmedical Financial Assistance Program on Missed Treatment Appointments Among Adults With Cancer.” Very exciting work. And I'm thrilled to tell you I have two of the authors here with me today. First is Dr. Caitlin Biddell. She's a Health Services Researcher at Mathematica Policy Research.

Welcome, Caitlin.

Dr. Caitlin Biddell: Thank you. Happy to be here.

Dr. Shannon Westin: And we also have Dr. Stephanie Wheeler. She is the Michael S. O'Malley Distinguished Professor in the Department of Health Policy and Management at the University of North Carolina, Chapel Hill, as well as being the Associate Director of Community Outreach and Engagement at UNC Lineberger Comprehensive Cancer Center.

Welcome.

Dr. Stephanie Wheeler: Thank you. Happy to be here as well.

Dr. Shannon Westin: Please note that our authors and participants have no conflicts of interest.

Let's get started. So first I would love to level set. Can you speak a little bit about what financial toxicity is and how common it is among patients with cancer?

Dr. Stephanie Wheeler: Sure, Shannon. I'm happy to take that one. This is Stephanie. So we know that financial hardship is often reported by patients and survivors who've experienced cancer. And as many as 50% of people with cancer have trouble with financial toxicity. There has been prior work that has conceptualized financial toxicity in three domains. So there's the material hardship, kind of the out-of-pocket material costs associated with cancer, which include both medical and nonmedical expenses. There is the stress and the psychosocial effects of that material hardship. And then there's coping behaviors that patients and their caregivers may employ to help deal with the high cost of cancer care. And as we've seen, cancer care increases in cost over time, and these expenditures really have very burdensome effects on patients and their families. We've been interested in looking at ways that we can try to mitigate that harm and really thinking about interventions in addition to the health policy changes that are needed to really ensure that this doesn't become a barrier to patients seeking and receiving the best quality care that they can.

Dr. Shannon Westin: I think that kind of leads pretty nicely into my next question, which is really: How does this toxicity potentially impact equitable cancer care delivery?

Dr. Stephanie Wheeler: Yeah, I'm happy to talk about that a little bit as well. So we know from prior research, including some of our own, that patients of color, those from rural areas, and those who are uninsured or underinsured face the largest financial burdens associated with their cancer care. So to the extent that those financial hardships influence people's ability to seek and continue with and complete their cancer care that's been recommended, this actually is directly in the pathway and a mechanism through which patients are not able to get recommended treatment and therefore can contribute to differences in cancer outcomes. So there's direct health impacts in terms of their ability to receive and respond to cancer treatment.

In addition to that, we know that this financial hardship contributes to household-level harms both economic and psychosocial in nature. And in some other work, this financial hardship has translated to worse quality of life, worse economic outcomes, things like being able to stay employed and seeking changes in employment or remaining within a particular position because you don't want to lose your insurance—this is referred to as “job lock”—or can also contribute to higher mortality. So there's been some really important work showing that financial toxicity is directly linked with cancer mortality.

And so, as we think about ways that we need to address this, it's really key to ensuring cancer health equity that we are thoughtful about multiple solutions implemented at multiple levels that can deal with not only the contributors to high cancer costs but that can also start to affect both the nonmedical and the medical components of this cost burden. And by nonmedical, I mean things like the cost associated with transportation and seeking care, accommodations for people who need to receive radiation therapy multiple days in a row at a different healthcare facility than where they live, childcare costs. These things really start to add up in addition to the medical costs associated with cancer treatment.

Dr. Shannon Westin: I really was intrigued by the intervention here that you all are studying around this Cancer Patient Assistance Fund. Can you tell me a little bit more about exactly what that was or is?

Dr. Caitlin Biddell: Yeah, absolutely. So this is a program at the North Carolina Basnight Cancer Hospital, located within the Lineberger Comprehensive Cancer Center, and it started back in 2013, actually, and has really grown in size. But the main goal of this program is to ensure that patients do not face the nonmedical financial barriers to care that Dr. Wheeler was just talking about. So thinking about giving patients gas cards so that they are able to drive to and from treatment. Lineberger has a catchment area of the entire state, so many people are coming a long distance to come for cancer treatment. They also provide things like lodging and accommodations, as Stephanie mentioned, and then even paying patients’ utility bills, things to keep them housed with electricity, the lights on, while they're undergoing cancer treatment. So just last year, in 2022, they distributed almost $350,000 to over 700 patients, and most of this is funded by philanthropic grants to ensure that patients can access the care they need. And it is a program that's really targeted to patients with low incomes. So they target patients with household incomes less than 250% of the federal poverty level.

Dr. Shannon Westin: And how does a patient get connected to the fund? How do they find it and get hooked up?

Dr. Caitlin Biddell: Yeah, there's a couple different ways. So one path is through the outpatient social work team. So they often perform distress screening for new cancer patients. So they use the Distress Thermometer, which was developed by the National Comprehensive Cancer Network. And it measures a variety of different factors that may be contributing to distress, but that does include financial stress, job stress, and the expense of daily living stress. And so, when a patient scores a certain amount on that thermometer, a social worker will meet with them for a full assessment. And then part of the referral pathway from that assessment includes the Cancer Patient Assistance Fund. Patients who are in inpatient will often be screened with the Social Determinants of Health Module, which is housed in the electronic health record. And so that can also generate referrals for assistance. And then beyond the kind of standard pathways, there's also many other ways that a patient may express concerns to a nurse, a care coordinator, an oncologist, and then that provider can reach out directly to the Cancer Patient Assistance Fund.

Dr. Shannon Westin: Your objective was to basically try to formally assess the impact of this fund on missed radiation or chemotherapy appointments. And so what was kind of your rationale for choosing this endpoint? And kind of take us through the design.

Dr. Caitlin Biddell: Yeah, absolutely. So the idea for this study actually came about from the program coordinator of the Cancer Patient Assistance Fund several years back. We were just having a conversation about the program. I was commenting how important I thought it was, how interesting it was. And she was saying, “You know, I know anecdotally that this program makes a difference, but we've never really known how to quantify that.” And that's becoming increasingly important as they apply for philanthropic grants and really need to show that their program is having an impact. So that's what originally started our plan for evaluating the program.

And then, in thinking about endpoints, of course we imagined this program could have an impact on a range of different endpoints. So missed appointments is quite practicable. We also imagine it could influence patient health-related quality of life, patient symptoms associated with their cancer treatment, even potentially other long-term outcomes like mortality. But for the purposes of this evaluation, we needed to identify an endpoint that we believed could be measured, the association could be measured, in the data we had. And so we had electronic health record data. Missed appointments is something that is routinely captured in the electronic health record data because it's an endpoint that matters financially to health systems. So they are regularly tracking missed or no-show appointments. And it's also an outcome that matters financially to the health system, so they want to reduce this.

So we thought if we measure the impact of this program on missed appointments, there's potentially an opportunity to kind of align financial incentives so that if we show that the program has an impact on missed appointments, then that could be something that could get decision makers at the health system level to say, well, that's also an endpoint that we want to reduce, and so let's think about ways that we can align resources to reduce missed appointments through potentially the Cancer Patient Assistance Fund and other mechanisms.

Dr. Shannon Westin: It's interesting because it definitely caught my eye because we give radiation, obviously, for gynecologic malignancies, and there's some pretty decent data that longer treatment duration for radiation has worse outcomes, with the implication that patients have missed appointments and so then, to finish their work, it takes longer, or to finish their treatment plan, it takes longer. So I definitely would be really intrigued to see the cancer-related outcomes. But I completely agree, like something practical, straightforward, and something easily obtained was the right way to start. I was just curious. So that's really interesting. So why don't you just walk us through the design of how you laid this out?

Dr. Caitlin Biddell: Yeah, absolutely. So we conducted a retrospective evaluation between 2015 and 2019, and we chose that time point to end before the COVID-19 pandemic since we know that had many impacts on missed appointments. And we compared the proportion of missed appointments in the six months following treatment initiation between patients who were receiving Cancer Patient Assistance Fund assistance and then propensity-weighted comparators. And this is really just a method to make the pool of potential comparison patients look as similar to those receiving Cancer Patient Assistance Fund assistance as possible so that we can really tease apart that direct effect of the Cancer Patient Assistance Fund and separate it out from other characteristics that may be influencing missed appointments.

So we had stratified our analysis by treatment type. We looked at radiation therapy, and then we also looked at oncology infusion, so specifically immunotherapy and chemotherapy. And to evaluate these endpoints, we used a couple of different data sources that we linked together. So the first and the primary data source was the electronic health record. So at UNC, we have EHR data for research purposes stored in a data warehouse that we were able to pull from. And then we also linked in UNC Health's portion of the North Carolina Cancer Registry to get that really important information on cancer stage, cancer type, and treatment start date. And then, of course, we pulled in program records from the Cancer Patient Assistance Fund to identify which patients were receiving assistance, how much, and at what time points. And so, essentially, using that data and thinking about missed appointment outcomes in those six months following treatment initiation, we created a couple different models. So we looked at the high versus low no-show proportion using a logistic regression. And then we also looked at just the continuous no-show proportion in the sample to see if there was an effect on that as well.

Dr. Shannon Westin: And what did you find? What was the impact of the fund’s support on your outcomes?

Dr. Caitlin Biddell: For radiation therapy, which I'll start with, the radiation therapy had a higher number of encounters, as we might expect, than immunotherapy/chemotherapy. There were a mean of 37 total radiation therapy encounters in the six-month follow-up period, and about 53% of the sample had one or more no shows. And so, then, when we looked at the impact the Cancer Patient Assistance Fund on radiation therapy missed appointments, we found that receipt of any assistance was associated with an eight-percentage-point decrease in the probability of having a no-show proportion in the highest quintile.

And then, when looking at continuous no-show proportion, we found it was associated with a 2.1-percentage-point decrease in the overall proportion of no shows, which corresponds to a 51% decrease in the overall mean no-show proportion. So a really substantial effect on radiation therapy missed appointments. And unsurprisingly, when we stratified the analysis by the amount of assistance received, we did see a greater impact of the program among patients receiving higher amounts of assistance.

Moving on to the oncology infusion cohort, this sample had a lower number of encounters in the follow-up period and less no shows, so only about 14% had one or more no shows. And so it potentially wasn't as surprising that we did not see an impact of the Cancer Patient Assistance Fund on infusion oncology missed appointments, though, of course, with the additional power and alternative analyses, it's not to say that there wasn't an effect, but in our population, we were not able to detect that.

Dr. Shannon Westin: Yeah, and that makes a lot of sense. I mean, radiation is so much more time intensive and having to come back and forth. And when you were describing the fund and saying, like, housing assistance, I was like, “Oh, well, there you go.” Because that, I feel like, is one of the major issues. At MD Anderson, we also kind of take care of a very large catchment area, and it can be a huge burden for patients to have to come for that 15-minute appointment every day. So, yeah, when I saw your results, I thought that was likely what you were hypothesizing was the reason. And certainly, the impact on radiation is so impressive. It’s just a hugely successful study and a hugely successful fund. So congratulations.

So, I guess, any other variables? You spoke a little bit about the amount of financial assistance received. Was there anything else that impacted the number of missed appointments in your study?

Dr. Caitlin Biddell: Yeah, because of our propensity-weighting design, we really didn't focus as much on other patient-level contributors to missed appointments. So we attempted to control for all of those things through the waiting and then kind of didn't add those into the final model. So that was really the main focus, was looking at the impact of the Cancer Patient Assistance Fund and then, of course, looking by amount of assistance. That was a really important finding and also, of course, needs to be taken in the context that every patient has different needs and so the amount of assistance may differ for every patient. And so there's always a need to kind of really assess what a patient's needs are and base the amount of assistance on that.

Dr. Stephanie Wheeler: It's probably worth saying again that the level at which we dichotomized these results was $180, which was sort of the median level of assistance provided. As you can imagine, there's a long tail, with some people receiving considerably more financial assistance. But I think it's really noteworthy that in the grand scheme of things, $180 per patient is a very small amount of money to provide to assist with things like housing support, transportation support, gas cards, and so forth.

And the program does not have strict rules about how those funds are used. So, in our setting, where we've got a lot of rural patients potentially traveling hours across state in their own vehicles, gas cards are really important for them. But in other settings—more urban settings, for example—having flexibility in how those funds are used could be really helpful for people who need bus assistance or other public transportation beyond kind of having to drive a private vehicle to appointments.

Dr. Shannon Westin: It is a great point, and it is incredible how much you can do with a fairly little amount of money. And when we were talking about healthcare spending, obviously, that's a lot of money to an individual or a family. But in the grand scheme of what we spend on healthcare, that is a very, very small amount. So really, again, congratulations.

So I think the last question I'll ask is just kind of what are the next steps? And really should we be making sure that we have these programs everywhere? Do I need to go back and make sure that this kind of situation is set up in my institution?

Dr. Stephanie Wheeler: Well, we also should share a little bit more about the economic evaluation results. Caitlin, why don't you describe that?

Dr. Caitlin Biddell: Yeah, absolutely. And this speaks exactly to what you were talking about in terms of the amount of assistance that can go a really long way for a patient and is a drop in the bucket for a health system. So we did want to look at what the cost-effectiveness, or the cost consequence, of this program was from the health system perspective. And so we conducted a decision tree analysis, which is a method used in economic evaluation research, using kind of a hypothetical cohort of 350 patients, that mean number of radiation therapy encounters, 37 encounters over a six-month time horizon. And we did find that under the current funding of the model, which essentially is that philanthropy covers all of the financial assistance and then UNC Lineberger covers the cost of the staffing and the indirect cost of housing the program, we found that this program was estimated to save the health system $153 per missed appointment averted.

And then, in kind of an additional threshold analysis we conducted to see how much could the health system chip into this program in some way, whether it's through indirect cost or direct financial assistance, while still kind of breaking even from the perspective of no shows averted, and it was around $100 per patient. So, of course, that would be split across patients in different ways. Not everyone might receive that same amount. But there is opportunity here for health systems to make investments in reducing patient nonmedical barriers to care in a way that will come back in the form of saved revenue from averting missed appointments.

Dr. Stephanie Wheeler: And the only thing I would add to that is this obviously was focused on those no-show appointments, but we anticipate that there's other financial benefits to the health system, like retention in care, patient satisfaction. There's a whole host of quality-of-life and clinical outcomes that are probably also benefited through use of this kind of nonmedical financial assistance program that we weren't able to measure. But I think part of our goal with this analysis is to start to make the case to hospitals and health systems that providing direct nonmedical financial assistance helps their bottom line as well.

Dr. Shannon Westin: We, as clinicians and researchers, always want the benefit to the patients. But I agree, when you're dealing with administrators, we also need to show that. So I think that is super clever and a really nice part of the design.

So what's next steps for your research?

Dr. Caitlin Biddell: Yeah, so I think we're currently kind of disseminating these findings within our own institution, so disseminating them back to the Cancer Patient Assistance Fund program so that they can use them in additional grant applications, but also really trying to get these findings in front of the health system administrators who might be able to make funding decisions surrounding this program. And then I think we are also thinking about ways to measure other endpoints beyond missed appointments. So we've kind of created this data set that involved some complicated linkages upfront, and now I do think there's opportunities to pull in other endpoints and even potentially some patient-reported endpoints as our electronic health records get better at collecting patient-reported data and even social determinant of health data, opportunities to really think about other impacts of this program.

And then I'll also add that there is talk among other groups at our institution about using this kind of approach to measure other similar programs. For example, we have a pretty large AYA program that does a lot of similar types of assistance and also psychosocial assistance. And so they're thinking about ways to use a similar methodology to evaluate some of their own work. So I think it's just kind of starting to open the door to thinking about how we can use the data we have within our institutions to really underscore the impacts that the programs that already exist are having on patients.

Dr. Stephanie Wheeler: I would only add to Caitlin's fabulous answer that dissemination of this is really critical because we know that NCI-Designated Conference of Cancer Centers, the vast majority of them provide some kind of direct medical and nonmedical financial assistance, but many of them have restrictions on who can access those funds and eligibility criteria that preclude patients with certain cancers from accessing those funds or patients with still what we would consider to be relatively high financial vulnerability to not be able to access those funds. In addition to that, we know that community oncology practices less often have access to these kinds of financial support resources. And so what often happens—and this is an extremely fragmented space for patients and their caregivers to be navigating—is that when nonmedical financial needs present, people are left to their own devices to have to search out, seek out, and identify programs for which they're eligible in the community. And these are often funded by philanthropic organizations, really wonderful healthcare support organizations. But oftentimes these types of financial supports are not directly provided through the hospital, or if they are, they're in the form of “charity care provisions,” which are often opaque to patients and their caregivers to even find. And then the eligibility requirements for those programs, again, are often preventing access for a number of patients in need.

So what I would like to see, as a person who does a lot of research in this space around financial hardship, is for that burden to be shifting away from patients and caregivers and more towards the systems that are treating these patients and that are supporting the caregivers so that people can focus on what's important during their cancer care, which is getting treatment that's recommended, staying in treatment, and attaining the best possible health that they can. When patients and their families spend hours and hours and days and weeks trying to understand existing financial support programs in the community and then those disappear or evaporate, as they do when funding and contributions subside, that really has a very detrimental impact on the patient's entire care experience. And I think it's on us, as people who are part of the healthcare system, to ensure that that doesn't happen. And the financial case to hospitals is clear, I think, from this analysis, but the moral case to all of us, as providers, should be clear and should be compelling in itself.

Dr. Shannon Westin: On that note, I think that's a perfect way to end. Thank you so much. This was such an intriguing discussion, and I really hope people are listening that are making the decisions for their hospitals and will see how they can implement something like this in their institution.

Again, this was a discussion of “Economic Evaluation of a Nonmedical Financial Assistance Program on Missed Treatment Appointments Among Adults with Cancer,” simultaneous publication in the JCO and presentation at the 2023 ASCO Quality Care Symposium on October 28th. It was great to have you all here. This was amazing, and I hope our listeners had a good time. And please do check out our other podcast offerings wherever you get your podcasts.

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Economic Evaluation of a Non-Medical Financial Assistance Program on Missed Treatment Appointments Among Adults With Cancer