Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

Becker, Nora; Scott, John W.; Moniz, Michelle H.; Carlton, Erin; Ayanian, John Z.

doi:10.1001/jamainternmed.2022.3687

Cited by 14 publications

(9 citation statements)

References 41 publications

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“…This is especially true as it pertains to the reverse causation between comorbidities and financial burden, which can result in food insecurity. 51,52 The income-to-poverty ratio in NHANES is top-coded at 500% to protect anonymity. This may have led to loss in data resolution.…”

Section: Discussionmentioning

confidence: 99%

Food Insecurity, Cardioprotective Diets, and Mortality Among US Adults

Ambrosini,

Fishman,

Mangalesh

et al. 2024

Preprint

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ImportanceThe DASH and Mediterranean diets are cardioprotective. Food insecurity (FI) limits access to healthy food. The relationship between FI, cardioprotective diets, and mortality is unknown.ObjectiveTo assess whether adherence to the DASH or Mediterranean diet affects all-cause and cardiovascular mortality independent of food insecurity. Furthermore, to evaluate if enrollment in the Supplemental Nutrition Assistance Program (SNAP) significantly affects diet quality and interacts with the relationship between cardioprotective diet adherence and mortality.Design, Setting, ParticipantsA retrospective cohort study using cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) including study cycles 1999-2018 and longitudinal mortality data from the National Death Index (NDI). NHANES is a weighted population-based study that represents the non-institutionalized civilian population in the United States. Adults age>18 years with complete food security, dietary recall, and mortality data were included.ExposuresAdherence to DASH or Mediterranean diet and food security status.Main outcomes and measuresAll-cause and cardiovascular disease (CVD) related mortality.Results51,193 eligible adults were analyzed, representing a weighted population size of 207.1 (200.1 – 214.2) million. Participants with FI were more likely to be younger, female, Black or Hispanic, smokers, obese, lower educational attainment, lower income, and less physically active. FI was a significant predictor of all-cause mortality (p=0.006) but not CVD mortality (p=0.263). After adjustment for multiple covariates and food security status, DASH diet non-adherence significantly predicted all-cause mortality in those with hypertension (p=0.038) and coronary heart disease (CHD) (p=0.001), and CVD mortality in CHD (p=0.041). Mediterranean diet non-adherence significantly predicted all-cause mortality across the entire study population (p=0.005). There was no significant interaction effect between adherence to cardioprotective diets and SNAP enrollment in prediction of all-cause or CVD mortality. Food security was a significant predictor of adherence to the Mediterranean diet (p=0.001). SNAP enrollment was associated with improved adherence to the DASH diet among food insecure individuals (p=0.024), and the Mediterranean diet among food secure individuals (p=0.001).Conclusions and relevanceThe relationship between FI and mortality is associated with diet quality. Expanding SNAP eligibility to include food security status may have positive effects on public health.Key pointsQuestionDoes adherence to the DASH or Mediterranean diet decrease all-cause and cardiovascular mortality, and is this related to food insecurity status?FindingsIndependent of food insecurity, impaired adherence to cardioprotective diets predicted increased risk of all-cause and cardiovascular disease mortality in select patient populations with hypertension or coronary heart disease. SNAP enrollment was not a significant effect modifier in the relationship between mortality and diet adherence, but it did predict increased adherence to the DASH diet in food insecure individuals.MeaningOur results support the hypothesis that mortality in FI is mediated by impaired diet quality.

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Section: Discussionmentioning

confidence: 99%

Food Insecurity, Cardioprotective Diets, and Mortality Among US Adults

Ambrosini,

Fishman,

Mangalesh

et al. 2024

Preprint

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“…13 In addition, our findings are aligned with prior work, which has demonstrated higher rates of medical debt among adults with more chronic medical conditions. 14 For these individuals, traumatic injuries may represent an acute-on-chronic financial stressor that is further compounded by work or income loss and may exacerbate the risk of forgoing care due to an inability to pay.…”

Section: Discussionmentioning

confidence: 99%

Multicenter Evaluation of Financial Toxicity and Long-Term Health Outcomes After Injury

Scott,

Anderson,

Conatser

et al. 2023

J Trauma Acute Care Surg

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Background Despite the growing awareness of the negative financial impact of traumatic injury on patients' lives, the association between financial toxicity and long-term health-related quality of life (hrQoL) among trauma survivors remains poorly understood. Methods Patients from nine trauma centers participating in a state-wide trauma quality collaborative had responses from longitudinal survey data linked to inpatient trauma registry data. Financial toxicity was defined based on patient-reported survey responses regarding medical debt, work or income loss, non-medical financial strain, and forgone care due to costs. A financial toxicity score ranging from 0 to 4 was calculated. HrQoL was assessed using the EuroQol 5 Domain (EQ-5D) tool. Multivariable regression models evaluated the association between financial toxicity and hrQoL outcomes while adjusting for patient demographics, injury severity and inpatient treatment intensity, and health systems variables. Results Among the 403 patients providing 510 completed surveys, rates of individual financial toxicity elements ranged from 21% to 46%, with 65% of patients experiencing at least one element of financial toxicity. Patients with any financial toxicity had worse summary measures of hrQoL and higher rates of problems in all five EQ-5D domains (p < 0.05 for all). Younger age, lower household income, lack of insurance, more comorbidities, discharge to a facility, and air ambulance transportation were independently associated with higher odds of financial toxicity (p < 0.05 for all). Injury traits and inpatient treatment intensity were not independently associated with financial toxicity. Conclusion A majority of trauma survivors in this study experienced some level of financial toxicity, which was independently associated with worse risk-adjusted health outcomes across all hrQoL measures. Risk factors for financial toxicity are not related to injury severity or treatment intensity, but rather to sociodemographic variables and measures of pre- and post-hospital healthcare resource utilization. Targeted interventions and policies are needed to address financial toxicity and ensure optimal recovery for trauma survivors. Study Type/Level of Evidence Observational Cohort Study / Level III

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“…Certain populations are especially vulnerable to incurring medical debt. These populations include racial and ethnic minority individuals, female individuals, younger individuals, rural residents, those with multiple chronic diseases or serious psychological distress, uninsured individuals, those with high-deductible insurance plans, individuals with limited health insurance literacy, and individuals living in states that have not expanded Medicaid income eligibility under the Patient Protection and Affordable Care Act (ACA) . Medical debt is adversely associated with multiple aspects of well-being, including delaying and forgoing recommended health care, prescription medication nonadherence, and food and housing insecurity .…”

Section: Introductionmentioning

confidence: 99%

Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US

Han,

Hu,

Zheng

et al. 2024

JAMA Netw Open

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ImportanceMedical debt is increasingly common in the US. Little is known regarding its association with population health.ObjectiveTo examine the associations of medical debt with health status, premature death, and mortality at the county level in the US.Design, Setting, and ParticipantsThis cross-sectional study was conducted at the US county level using 2018 medical debt data from the Urban Institute Debt in America project linked with 2018 data on self-reported health status and premature death from the County Health Rankings &amp; Roadmaps and with 2015 to 2019 mortality data from the National Center for Health Statistics. Data analysis was performed from August 2022 to May 2023.ExposureShare of population with any medical debt in collections and median amount of medical debt.Main Outcomes and MeasuresHealth status was measured as (1) the mean number of physically and mentally unhealthy days in the past 30 days per 1000 people, (2) the mean number of premature deaths measured as years of life lost before age 75 years per 1000 people, and (3) age-adjusted all-cause and 18 cause-specific mortality rates (eg, malignant cancers, heart disease, and suicide) per 100 000 person-years. Multivariable linear models were fitted to estimate the associations between medical debt and health outcomes.ResultsA total of 2943 counties were included in this analysis. The median percentage of the county population aged 65 years or older was 18.3% (IQR, 15.8%-20.9%). Across counties, a median 3.0% (IQR, 1.2%-11.9%) of the population were Black residents, 4.3% (IQR, 2.3%-9.7%) were Hispanic residents, and 84.5% (IQR, 65.7%-93.3%) were White residents. On average, 19.8% (range, 0%-53.6%) of the population had medical debt. After adjusting for county-level sociodemographic characteristics, a 1–percentage point increase in the population with medical debt was associated with 18.3 (95% CI, 16.3-20.2) more physically unhealthy days and 17.9 (95% CI, 16.1-19.8) more mentally unhealthy days per 1000 people during the past month, 1.12 (95% CI, 1.03-1.21) years of life lost per 1000 people, and an increase of 7.51 (95% CI, 6.99-8.04) per 100 000 person-years in age-adjusted all-cause mortality rate. Associations of medical debt and elevated mortality rates were consistent for all leading causes of death, including cancer (1.12 [95% CI, 1.02-1.22]), heart disease (1.39 [95% CI, 1.21-1.57]), and suicide (0.09 [95% CI, 0.06-0.11]) per 100 000 person-years. Similar patterns were observed for associations between the median amount of medical debt and the aforementioned health outcomes.Conclusions and RelevanceThese findings suggest that medical debt is associated with worse health status, more premature deaths, and higher mortality rates at the county level in the US. Therefore, policies increasing access to affordable health care, such as expanding health insurance coverage, may improve population health.

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Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

Cited by 14 publications

References 41 publications

Food Insecurity, Cardioprotective Diets, and Mortality Among US Adults

Food Insecurity, Cardioprotective Diets, and Mortality Among US Adults

Multicenter Evaluation of Financial Toxicity and Long-Term Health Outcomes After Injury

Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US

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