Financial Toxicity After Acute Respiratory Distress Syndrome: A National Qualitative Cohort Study*

Abstract

Objective: The financial burdens and subsequent related distress of medical care, referred to as financial toxicity, may limit access to beneficial treatments. However, financial toxicity after acute care is less described-but may be an important but underexplored mechanism preventing full recovery after critical illnesses such as Acute Respiratory Distress Syndrome (ARDS). We sought to identify the mechanisms by which financial toxicity manifested in patients with ARDS, protective factors against such toxicity, and the consequences of financial toxicity to survivors' lives following ARDS. Design:We conducted semi-structured interviews following patients' hospitalization and during recovery as an ancillary study to a multi-center RCT in ARDS. Patients were 9-16 months post randomization at the time of interview. Setting and participants:The ROSE trial examined the use of early neuromuscular blockade in mechanically ventilated patients with moderate/severe ARDS. We recruited consecutive surviving patients from 29 U.S. sites who were English speaking, consented to follow-up, and were randomized between 11/12/2017 and 4/5/2018 (N=79). Measurements and Main Results:We asked about patients' perceptions of financial burden(s) that they associated with ARDS hospitalization. 46 of 79 (58%) of eligible ARDS survivors participated (from 22 sites); their median age was 56 (IQR 46, 63). 31 of 46 reported at least one ARDS-related financial impact. Financial toxicity manifested via medical bills, changes in insurance coverage, and loss of employment income. Respondents reported not working prior to ARDS, using Medicaid or Medicare, or, conversely, generous work benefits as factors which may have limited financial burdens. Patients reported multiple consequences of ARDS-related Financial Toxicity After ARDS 4 financial toxicity, including harms to their mental and physical health, increased reliance on others, and specific material hardships.Conclusions: Financial toxicity related to critical illness is common and may limit patients' emotional, physical, and social recovery after ARDS hospitalization for at least a year.

Financial Toxicity After Hospitalization; Considerations in Coronavirus Disease 2019 Recovery*

“…Forty-six patients agreed to participate in interviews, of which 67% reported some form of negative financial impact they attributed to their ARDS hospitalization. Although this is a small study, the authors found, at a very granular level, that patients who acquired medical expenses as a result of their ARDS hospitalization experienced financial toxicity that outweighed their available resources ( 7 ). Some patients described their financial toxicity as limiting their recovery by causing adverse mental health effects and altering their medication or rehabilitation compliance due to an inability to pay.…”

“…Although the macro estimates for these healthcare costs are substantial, they fail to account for the human and financial impact on individual patients and families at the micro level. In this issue of Critical Care Medicine , the article by Hauschildt et al ( 7 ) provides a rare opportunity to give audience to the micro level financial experience after an ICU stay from the patient’s perspective and how the consequential costs either burdened or buffered the patient’s recovery ( 7 ).…”

“…Hauschildt et al ( 7 ) conducted semi-structured phone interviews as an adjunct to the Reevaluation of Systematic Early Neuromuscular Blockade multicenter randomized clinical trial at 9–16 months following hospitalization for critical illness and acute respiratory distress syndrome (ARDS). Patients were screened for financial toxicity, which the authors defined as “objective” financial burden or “subjective” financial distress resulting from out-of-pocket costs associated with medical treatment.…”

“…Also, efforts to improve recovery care could minimize patient disability and increase the patient’s ability to return to work. Last, patients who identify as being at risk for a limited recovery due to financial toxicity could be referred to resources that assist patients with managing costs ( 7 ).…”

“…The methodology may not adequately account for the multilevel response characteristics at each site and the number of patients included is very low. Second, the descriptive nature of qualitative research and the small sample size in the study by Hauschildt et al ( 7 ) creates limitations in forming generalizable results. Because results were based on patient perspective rather than a formal quantitation, those who participated in interviews could have been skewed by recall and/or selective disclosure bias.…”