Association between Food Insecurity, Financial Toxicity, and Healthcare Utilization in Patients with Lymphoma

Background:

Patients with cancer experience high rates of financial toxicity (FT), defined as the “harmful personal financial burden faced by patients receiving cancer therapy,” and unmet health-related social needs (HRSN: food, housing, transportation insecurity). Nationally representative studies among patients with lymphoma indicate that one in 10 meet criteria for food insecurity (FI), a modifiable HRSN impacting a wide array of health outcomes. Two such outcomes are emergency room (ED) visits and hospitalizations, both of which strain the individual patient and the healthcare system. At present, associations between FI, FT, and ED visits or hospitalizations remain unclear. Leveraging systematically collected HRSN data from a diverse cohort of patients with lymphoma, we evaluated (1) rates of FT and HRSN, and (2) associations between FT or unmet needs and healthcare utilization.

Methods:

Patients treated for lymphoma at a large, urban cancer center from November 2022 - June 2024, who utilized the electronic health record (EHR) to check in for clinic visits, completed an 8-item HRSN survey and a 2-item FT tool adapted from the Comprehensive Score of Financial Toxicity (COST) measure. ED visits and hospitalizations were extracted from the EHR directly. Patients were included if they had at least two clinic encounters and at least one complete survey (FT or HRSN). Descriptive statistics characterized the cohort, and chi-square tests examined associations between FI or FT and utilization. A p-value <0.05 was significant.

Results

Screening surveys from N=569 patients undergoing outpatient therapy for lymphoma were included; N=113 completed FT surveys, N=456 completed HRSN surveys, and N =106 completed both. The majority of surveys were done in English (89% of FT; 68% of HRSN). The median age of FT survey respondents was 64 years (range: 47-73); 58% of these patients were non-Hispanic White (NHW), 20% were Hispanic, 6% were non-Hispanic Black (NHB). The median age for those completing the HRSN survey was 66 years (range 54-76); 36% were NHW, 37% were Hispanic, and 9.2% were NHB.

Of the 113 patients who completed the FT survey, 56% (n=63) screened positive. These patients were significantly more likely to have at least one ED visit compared with those who screened negative (32% v. 12%, p=0.01). Among patients with high FT, 38% (n=24) were hospitalized at least once, compared with 28% (n=14) of those with low or moderate FT (p=0.26).

Of the 456 patients who completed the HRSN survey, 13% (N=58) screened positive for FI. Of these, a significantly higher proportion had at least one ED visit compared to those without FI (48% v. 29%; p<0.01). There was no significant difference in likelihood of hospitalization based on FI (p=0.10). Of the 106 patients who completed both surveys, 20% (N=21) screened positive for FI, 91% (N=19) of whom also had high FT.

Conclusions:

Systematic screening for FI, FT or other HRSN is a critical step toward addressing inequities in cancer care delivery and reducing outcome disparities among vulnerable populations. Our preliminary data indicate that FI and FT may be risk factors for increased ED visits in patients getting outpatient therapy for lymphoma. Ongoing analyses are evaluating reasons for ED visits and changes in FT or FI over time.