What question did this study set out to answer?

To investigate how adverse financial events affect health care use and costs at the end of life in cancer patients.

April 22, 2026JAMA Network Open0 citationsOpen Access

Financial Hardship, End-of-Life Health Care Use, and Costs in Patients With Cancer

VSVeena Shankaran LLL LiCape Town HVTN Immunology Laboratory / Hutchinson Centre Research Institute of South Africa SKSara KhorCARE USA

Key Points

To investigate how adverse financial events affect health care use and costs at the end of life in cancer patients.
Cohort study linking cancer registry data with claims and credit records.
Analyzed emergency and inpatient visits in the last 3 months of life based on financial hardship.
Employs multivariate logistic regression and 2-part models for cost analysis.
Patients with financial hardships had higher odds of emergency and inpatient visits (OR, 1.41) and were more likely to die in a hospital (OR, 1.50).
Mean health care costs were significantly higher in those with adverse financial events, showing an incremental increase of $4084 in the last 3 months.
Overall costs were also higher in the last 6 months, with a mean increase of $5799 associated with financial hardships.

Abstract

Importance Patients with cancer are at higher risk of adverse financial events (AFEs) compared with individuals without cancer. However, little is known about how personal finances affect cancer care, particularly at the end of life (EOL). Objective To investigate the association between AFEs and health care use and costs at EOL among patients with cancer. Design, Setting, and Participants In this cohort study, Western Washington Surveillance, Epidemiology, and End Results cancer registry cases were linked to claims from commercial payers and Medicare and to credit records from TransUnion. Patients with American Joint Committee on Cancer stage I to IV solid tumors who died between January 1, 2013, and December 31, 2019, were identified. Data analysis was performed from January 2023 and June 2025. Main Outcomes and Measures Emergency department (ED) and inpatient visits in the last 3 months of life, place of death, and mean adjusted health care costs per patient were compared between patients with vs without new AFEs in the 2 years preceding EOL (charge-offs, third-party collections, tax liens, delinquent mortgage payments, foreclosures, or repossessions). A multivariate logistic regression analysis evaluated the association between AFEs and the outcomes of ED or inpatient visits and inpatient death. Health care costs in the last 3 and 6 months of life were analyzed using 2-part models to account for zero costs and right-skewed positive expenditures; adjusted average treatment effects were estimated. Results A total of 10 826 patients (median IQR age, 75 69-83 years; 5877 54% male; 932 8. 6% with AFEs) were included. Patients with AFEs were more likely to have multiple ED or inpatient visits (odds ratio OR, 1. 41; 95% CI, 1. 22-1. 62; P lt;. 001) and die in a hospital (OR, 1. 50; 95% CI, 1. 30-1. 75; P lt;. 001). Mean (SD) adjusted total health care costs were higher in patients with AFEs than those without in the last 3 months (35 115 1415 vs 31 031 389) and 6 months (57 401 2181 vs 51 602 581) of life, yielding a mean adjusted incremental costs in the AFE group of 4084 (95% CI, 1287-7087; P =. 006) and 5799 (95% CI, 1235-9996; P =. 01), respectively. Conclusions and Relevance In this cohort study, AFEs were associated with greater ED and inpatient use, higher risk of inpatient death, and higher care costs at EOL. These findings point to the need for future studies investigating whether interventions that mitigate financial hardship could improve the EOL experience and decrease health care costs for patients with cancer.

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