Financial Toxicity Order Set: Implementing a Simple Intervention to Better Connect Patients With Resources.

PURPOSE: Financial toxicity of cancer treatment is well described in the literature, including characterizations of its risk factors, manifestations, and consequences. There is, however, limited research on interventions, particularly those at the hospital level, to address the issue. METHODS: From March 1, 2019, to February 28, 2022, a multidisciplinary team conducted a three-cycle Plan-Do-Study-Act (PDSA) process to develop, test, and implement an electronic medical record (EMR) order set to directly refer patients to a hospital-based financial assistance program. The cycles included an assessment of the efficacy of our current practice in connecting patients experiencing financial hardship with assistance, the development and piloting of the EMR referral order, and the broad implementation of the order set across our institution. RESULTS: In PDSA cycle 1, we found that approximately 25% of patients at our institution experienced some form of financial hardship, but most patients were not connected to available resources because of our referral mechanism. In PDSA cycle 2, the pilot referral order set was deemed feasible and received positive feedback. Over the 12-month study period (March 1, 2021-February 28, 2022) of PDSA cycle 3, 718 orders were placed for 670 unique patients across interdisciplinary providers from 55 treatment areas. These referrals resulted in at least $850,000 in US dollars (USD) in financial aid in 38 patients (mean = $22,368 USD). CONCLUSION: The findings from our three-cycle PDSA quality improvement project demonstrate the feasibility and efficacy of interdisciplinary efforts to develop a hospital-level financial toxicity intervention. A simple referral mechanism can empower providers to connect patients in need with available resources.

Risk factors for financial toxicity in patients with gynecologic cancer.

BACKGROUND: The cost of cancer care is high and rising. Evidence of increased patient cost burden is prevalent in the medical literature and has been defined as "financial toxicity," the financial hardship and financial concerns experienced by patients because of a disease and its related treatments. With targeted therapies and growing out-of-pocket costs, patient financial toxicity is a growing concern among patients with gynecologic cancer. OBJECTIVE: This study aimed to determine the prevalence of financial toxicity and identify its risk factors in patients with gynecologic cancer treated at a large cancer center using objective data. STUDY DESIGN: Using institutional databases, we identified patients with gynecologic cancer treated from January 2016 to December 2018. Patients with a preinvasive disease were excluded. Financial toxicity was defined according to institutionally derived metrics as the presence of ≥1 of the following: ≥2 bills sent to collections, application or granting of a payment plan, settlement, bankruptcy, financial assistance program enrollment, or a finance-related social work visit. Clinical characteristics were gathered using a 2-year look-back from the time of the first financial toxicity event or a randomly selected treatment date for those not experiencing toxicity. Risk factors were assessed using chi-squared tests. All significant variables on univariate analysis were included in the logistic regression model. RESULTS: Of the 4655 patients included in the analysis, 1155 (25%) experienced financial toxicity. In the univariate analysis, cervical cancer (35%), stage 3 or 4 disease (24% and 30%, respectively), younger age (35% for age <30 years), nonpartnered marital status (31%), Black (45%) or Hispanic (37%) race and ethnicity, self-pay (48%) or commercial insurance (30%), clinical trial participation (31%), more imaging studies (39% for ≥9), ≥1 emergency department visit (36%), longer inpatient stays (36% for ≥20 days), and more outpatient clinician visits (41% for ≥20 visits) were significantly associated with financial toxicity (P<.01). In multivariate analysis, younger age, nonpartnered marital status, Black and Hispanic race and ethnicity, commercial insurance, more imaging studies, and more outpatient physician visits were significantly associated with financial toxicity. CONCLUSION: Financial toxicity is an increasing problem for patients with gynecologic cancer. Our analysis, using objective measures of financial toxicity, has suggested that demographic factors and healthcare utilization metrics may be used to proactively identify at-risk patients for financial toxicity.

Hospital strategies to engage physicians in quality improvement.

In the last decade, growing evidence that the quality of U.S. health care is uneven at best has prompted greater attention to quality improvement, especially in the nation's hospitals. While physicians are integral to hospital quality improvement efforts, focusing physicians on these activities is challenging because of competing time and reimbursement pressures. To overcome these challenges, hospitals need to employ a variety of strategies, according to a Center for Studying Health System Change (HSC) study of four communities--Detroit, Memphis, Minneapolis-St. Paul and Seattle. Hospital strategies include employing physicians; using credible data to identify areas that need improvement; providing visible support through hospital leadership; identifying and nurturing physician champions to help engage physician peers; and communicating the importance of physicians' contributions. While hospitals are making gains in patient care quality, considerably more progress likely could be made through greater alignment of hospitals and physicians working together on quality improvement.

Massachusetts health reform: high costs and expanding expectations may weaken employer support.

Passage of health reform legislation in Massachusetts required significant bipartisan compromise and buy in among key stakeholders, including employers. However, findings from a recent follow-up study by the Center for Studying Health System Change (HSC) suggest two important developments may threaten employer support as the reform plays out. First, improved access to the non-group--or individual--insurance market, the availability of state-subsidized coverage, and the costs of increased employee take up of employer-sponsored coverage and rising premiums potentially weaken employers' motivation and ability to provide coverage. Second, employer frustration appears to be growing as the state increases employer responsibilities. While the number of uninsured people has declined significantly, the high cost of the reform has prompted the state to seek additional financial support from stakeholders, including employers. Improving access to health care coverage has been a clear emphasis of the reform, but little has been done to address escalating health care costs. Yet, both must be addressed, otherwise long-term viability of Massachusetts' coverage initiative is questionable.

A health plan work in progress: hospital-physician price and quality transparency.

Responding to large employers' interest in greater health care price and quality transparency, health plans are developing consumer tools to compare price and quality information across hospitals and physicians, but the tools' pervasiveness and usefulness are limited, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Many large employers view price and quality transparency as key to a broader consumerism strategy, where employees take more responsibility for medical costs, lifestyle choices and treatment decisions. Some health plans believe providing price and quality information to enrollees is a competitive advantage, while others are skeptical about the benefits and are proceeding cautiously to avoid potential unintended consequences. Health plans are in various stages of making price information available to enrollees. Plans generally provide some type of price information on inpatient and outpatient procedures and services from data based on their own negotiated prices or through aggregated health plan claims data obtained through a vendor; few plans provide price information on services in physician offices. However, the information provided often lacks specificity about individual providers, and its availability is often limited to enrollees in specific geographic areas. Health plans generally rely on third-party sources to package publicly available quality information instead of using information gleaned from their own claims or other data. Health plans' ability to advance price and quality comparison tools to the point where a critical mass of consumers trust and use the information to choose physicians and hospitals will likely have considerable influence on the ultimate success of broader health consumerism efforts.

Developing health system surge capacity: community efforts in jeopardy.

Since Sept. 11, 2001, communities have responded to the federal call to enhance health care surge capacity--the space, supplies, staffing and management structure to care for many injured or ill people during a terrorist attack, natural disaster or infectious disease pandemic. Communities with varied experience handling emergencies are building broad surge capacity, including transportation, communication, hospital care and handling mass fatalities, according to a new study by the Center for Studying Health System Change (HSC). Communities rely on federal funding to help coordinate and plan across agencies and providers, conduct training and drills, recruit volunteers, and purchase equipment and stockpile supplies. The current federal focus on pandemic influenza has helped prepare for all types of emergencies, although at times communities struggle with fragmented and restrictive funding requirements. Despite progress, communities face an inherent tension in developing surge capacity. The need for surge capacity has increased at the same time that daily health care capacity has become strained, largely because of workforce shortages, reimbursement pressures and growing numbers of uninsured people. Payers do not subsidize hospitals to keep beds empty for an emergency, nor is it practical for trained staff to sit idle until a disaster hits. To compensate, communities are trying to develop surge capacity in a manner that supports day-to-day activities and stretches existing resources in an emergency. Many of these efforts--including integrating outpatient providers, expanding staff roles and adapting standards of care during a large-scale emergency--require greater coordination, guidance and policy support. As time passes since 9/11 and Hurricane Katrina, federal funding for surge capacity has waned, and communities are concerned about losing surge capacity they have built.

The role of nurses in hospital quality improvement.

As the nation's hospitals face increasing demands to participate in a wide range of quality improvement activities, the role and influence of nurses in these efforts is also increasing, according to a new study by the Center for Studying Health System Change (HSC). Hospital organizational cultures set the stage for quality improvement and nurses' roles in those activities. Hospitals with supportive leadership, a philosophy of quality as everyone's responsibility, individual accountability, physician and nurse champions, and effective feedback reportedly offer greater promise for successful staff engagement in improvement activities. Yet hospitals confront challenges with regard to nursing involvement, including: scarcity of nursing resources; difficulty engaging nurses at all levels--from bedside to management; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today's contemporary hospital setting. Because nurses are the key caregivers in hospitals, they can significantly influence the quality of care provided and, ultimately, treatment and patient outcomes. Consequently, hospitals' pursuit of high-quality patient care is dependent, at least in part, on their ability to engage and use nursing resources effectively, which will likely become more challenging as these resources become increasingly limited.

Dampness and mold in the home and depression: an examination of mold-related illness and perceived control of one's home as possible depression pathways.

OBJECTIVES: We evaluated a previously reported association between residence in a damp and moldy dwelling and the risk of depression and investigated whether depression was mediated by perception of control over one's home or mold-related physical illness. METHODS: We used survey data from 8 European cities. A dampness and mold score was created from resident- and inspector-reported data. Depression was assessed using a validated index of depressive symptoms. RESULTS: Dampness or mold in the home was associated with depression (odds ratio [OR]=1.39, 1.44, and 1.34, for minimal, moderate, and extensive exposure, respectively, compared with no exposure). This association became attenuated when perception of control (OR=1.34, 1.40, and 1.24; global P=.069) or a physical health index (OR = 1.32, 1.37, and 1.15; global P= .104) was included in the model. The mediation effects of perception of control over one's home and by physical health appeared to be additive. CONCLUSIONS: Dampness and mold were associated with depression, independent of individual and housing characteristics. This association was independently mediated by perception of control over one's home and by physical health.

Physicians moving to mid-sized, single-specialty practices.

The proportion of physicians in solo and two-physician practices decreased significantly from 40.7 percent to 32.5 percent between 1996-97 and 2004-05, according to a national study from the Center for Studying Health System Change (HSC). At the same time, the proportion of physicians with an ownership stake in their practice declined from 61.6 percent to 54.4 percent as more physicians opted for employment. Both the trends away from solo and two-physician practices and toward employment were more pronounced for specialists and for older physicians. Physicians increasingly are practicing in mid-sized, single-specialty groups of six to 50 physicians. Despite the shift away from the smallest practices, physicians are not moving to large, multispecialty practices, the organizational model that may be best able to support care coordination, quality improvement and reporting activities, and investments in health information technology.

Massachusetts health reform: employers, lower-wage workers and universal coverage.

As Massachusetts' landmark effort to reach nearly universal health coverage unfolds, the state is now focusing on employers to take steps to increase coverage. All employers--except firms with fewer than 11 workers--face new requirements under the 2006 law, including establishing Section 125, or cafeteria, plans to allow workers to purchase insurance with pre-tax dollars and paying a $295 annual fee if they do not make a "fair and reasonable" contribution to the cost of workers' coverage. Through interviews with Massachusetts health care leaders (see Data Source), the Center for Studying Health System Change (HSC) examined how the law is likely to affect employer decisions to offer health insurance to workers and employee decisions to purchase coverage. Market observers believe many small firms may be unaware of specific requirements and that some could prove onerous. Moreover, the largest impact on small employers may come from the individual mandate for all residents to have a minimum level of health insurance. This mandate may add costs for firms if more workers take up coverage offers, seek more generous coverage or pressure employers to offer coverage. Despite reform of the individual and small group markets, including development of new insurance products, concerns remain about the affordability of coverage and the ability to stem rising health care costs.

High-performance health plan networks: early experiences.

Health plans have introduced high-performance networks to encourage use of network providers--predominantly physician specialists--deemed high performing on efficiency and quality measures. Early adopters of these networks are large national employers, and, while other employers are interested, actual adoption has lagged, according to a study by the Center for Studying Health System Change (HSC). Enrollment in products using high-performance networks is limited, and objective evidence on the impact on service use, costs and quality is lacking. Early lessons learned indicate the need for effective communication between plans and providers, use of both efficiency and quality measures, industry standards of provider performance, and employer support.

Perceived safety of area of residence and exercise: a pan-European study.

The authors examined the association between perceived safety of neighborhood and likelihood of exercise among adult residents of eight European cities. Data were collected by a survey of neighborhood, housing, and health conducted by the World Health Organization in 2002 and 2003. Baseline category logistic regression models were fit to estimate the association between perceived safety and exercise, accounting for demographic and place-of-residence characteristics. Among women, perception of safety was associated with a 22% (95% confidence interval: 1.00, 1.54) and a 40% (95% confidence interval: 1.03, 1.91) elevation in the odds of occasional and frequent exercise, respectively. Among men, perception of safety was associated with a 39% elevation in the odds of occasional exercise, but there was no association with frequent exercise. If these findings were replicated, they would suggest that health promotion efforts could target residential areas without the need to identify specific persons.