Financial Toxicity in ESKD

Abstract

Key Points:

1. Adults with kidney failure experience financial toxicity as measured by the Comprehensive Score for Financial Toxicity tool.

2. Adults with kidney failure experiencing financial toxicity report a high rate of reduced workforce participation.

3. Although financial toxicity persists through many stages of kidney failure treatment, it is most prevalent among those on dialysis.

Background: Patients with kidney failure require treatments that are demanding and time intensive, potentially interfering with employability and leading to indirect costs. We sought to characterize the prevalence and risk factors of financial toxicity among patients with kidney failure.

Methods: We conducted a cross-sectional survey study of 112 participants with kidney failure at a large, urban, academic medical center. Financial toxicity was assessed by using a survey that included the validated Comprehensive Score for Financial Toxicity (CoST) tool as well as additional items to evaluate self-reported changes in material conditions and financial coping behaviors. Participants were grouped according to KRT modality (dialysis, transplant after dialysis, or preemptive transplant). Descriptive statistics were used to summarize demographic and clinical characteristics of the study population and to compare those with above-median versus below-median CoST scores and by modality of KRT.

Results: The median CoST score was 17, with 71% of participants experiencing at least mild financial toxicity. Participants experiencing financial toxicity were less likely to have White race and more likely to be receiving dialysis. Over half of participants reported reduction in employment (61%) or income (57%) after kidney failure onset with the greatest likelihood of these among participants with any dialysis.

Conclusions: Adults with kidney failure experience significant financial toxicity as measured by the CoST score and report significant negative changes in employment and income. Although this toxicity persists through many stages of treatment, treatment modality may affect financial burdens experienced by patients with kidney failure.

Keywords: ESKD; dialysis; economic impact; health policy; kidney failure; minority health and disparities; quality of life; social determinants of health; transplantation.

Graphical abstract

Figure 1

Distribution of CoST scores among patients included in the primary analysis. Lower CoST scores indicate a higher degree of financial toxicity/psychological distress. Scored vertical lines indicate thresholds for mild (14–26), moderate (1–13), or severe (0) financial toxicity. CoST, Comprehensive Score for Financial Toxicity.

Figure 2

Financial toxicity and changes to material conditions and coping behaviors in kidney failure. Self-reported changes to (A) material conditions and (B) use of coping behaviors after kidney failure diagnosis, by presence of above-median or below-median CoST score. (A) Percentage of all respondents who reported a reduction in income <50% or >50%, a change in employment of “stopped working” or “reduced working hours,” responded “no” to “Is your income enough to meet your basic/medical needs?” or responded “a lot” or “a great deal” to “Approximately how much do you spend each month out of pocket on costs related to your kidney disease?” (B) Percentage of all respondents who responded “yes” or (where denoted by *) who responded “often” or “always.”

Figure 3

Distribution of CoST scores among patients by KRT modality, with lower scores indicating a higher degree of financial toxicity/psychological distress. Scored horizontal line denotes the group median CoST score of 17.

Figure 4

KRT modality and changes to material conditions and coping behaviors. Self-reported changes to (A) material conditions and (B) use of coping behaviors after kidney failure diagnosis by KRT modality. (A) Percentage of all respondents who reported a reduction in income <50% or >50%, a change in employment of “stopped working” or “reduced working hours,” responded “no” to “Is your income enough to meet your basic/medical needs?” or responded “a lot” or “a great deal” to “Approximately how much do you spend each month out of pocket on costs related to your kidney disease?” (B) Percentage of all respondents who responded “yes” or (where denoted by *) who responded “often” or “always.” **Preemptive transplant recipients were not presented with this question.

Figure 5

Conceptual diagram depicting relationship between interrelated components of financial toxicity.