High financial burden drives depression, poor quality of life in ASCVD patients

Patients with atherosclerotic cardiovascular disease (ASCVD) who struggle to pay their medical bills are at a higher risk for psychological distress, depression and a poor quality of life, according to research published in Circulation: Cardiovascular Quality and Outcomes.

In an analysis of nine-year MEPS (Medical Expenditure Panel Survey) data, Amarnath Annapureddy, MD, and colleagues studied the ratio of ASCVD patients’ annual out-of-pocket (OOP) expenses to their post-subsistence family income. They said the national average OOP spending for family members with ASCVD is around $2,227, including $722 in insurance premiums.

“In the United States, ASCVD care costs are substantial and can often lead to significant financial burden,” Annapureddy, of the Center for Outcomes Research and Evaluation at Yale New Haven Health, and coauthors wrote. “Currently, there is little information about the relationship between the financial burden of healthcare for patients with ASCVD and their health-related quality of life (HRQoL).”

The researchers studied 20,131 individuals aged 40 and up, all of whom had been diagnosed with ASCVD between 2006 and 2015. Participants’ HRQoL was assessed using the physical and mental health component summaries from the 12-item short-form (SF-12) Health Survey Version 2, where a higher score indicates a better HRQoL and a difference of three points or greater signifies a clinically significant disparity. Financial burden was defined in the study as the ratio of family annual OOP expenditures to post-subsistence family income, with a ratio between 20 percent and 40 percent indicating a high financial burden and a ratio of more than 40 percent indicating catastrophic healthcare expenditure.

Annapureddy et al. found that 16 percent of patients included in the study were part of families with high financial burden, and 7.6 percent were part of families with catastrophic healthcare expenditures. People whose financial burden stemmed from OOP costs were more likely to be white, have a lower income and have a higher number of comorbidities and CVD risk factors.

The authors said they observed a “significant trend” of lower average HRQoL values across worsening financial burden categories. Patients with a high financial burden or catastrophic health expenditure had mean SF-12 physical component scores of 34.5 and 32.9, respectively, compared to 38.0 in patients with no financial burden. SF-12 mental component scores were 46.9 and 44.9 in patients with high or catastrophic financial burden, respectively, and 48.5 in patients with no burden.

“Accounting for demographics, family income and disease burden, compared to those without financial burden, adults with ASCVD and high financial burden or catastrophic healthcare expenditure had 1.26 to 1.44 and 1.58 to 2.00 higher odds of poor mental and physical quality of life, respectively,” Annapureddy and coauthors wrote. They said individuals with catastrophic healthcare expenditure were also more likely to report worse health status, high psychological distress and a higher risk for depression.

“Our study contributes to increasing awareness of financial burden as a potential adverse effect of medical care in these patients,” the researchers said. “As out-of-pocket cost sharing for these patients continues to rise, future efforts should be expanded to identify pragmatic approaches not only to limit financial toxicity from regular care but also to assess the potential impact on meaningful patient-centric outcomes including quality of life and psychological well-being.”