Comparing the association between out‐of‐pocket cost burden and cost‐related care avoidance among individuals with and without a history of cancer

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INTRODUCTION: Out-of-pocket (OOP) cost is routinely captured by payers and health systems and may help identify individuals at risk of cost-related care avoidance. This study aimed to evaluate the relationship between OOP cost burden relative to household income (OOP:HHI) and cost-related care avoidance and to assess whether this relationship differs by cancer history. METHODS: A retrospective cross-sectional study was conducted leveraging data from multiple survey waves of the Understanding America Study (2015-2024). Adults aged ≥18 years with data on OOP health care expenditure, household income, and cost-related care avoidance were included. Mixed-effects logistic models with random intercepts were used to assess associations between OOP:HHI and care avoidance, adjusting for respondent characteristics. Effect modification by cancer history was examined. Classification performance of OOP:HHI alone versus multivariable models was evaluated using receiver operating characteristic curves. RESULTS: The analysis included 21,299 responses from 10,811 respondents, of which 2180 responses were from 1052 respondents with cancer history. Higher OOP:HHI was independently associated with increased odds of cost-related care avoidance (adjusted odds ratio per 1% increase = 1.03; 95% CI, 1.02-1.04) with similar trends in both cancer and noncancer subgroups. OOP:HHI alone showed modest discrimination, whereas multivariable models demonstrated excellent performance in identifying respondents who indicated care avoidance. CONCLUSION: Higher OOP cost burden was associated with cost-related care avoidance regardless of cancer history, but cost burden alone was insufficient for risk identification. Integrating OOP costs with routinely available patient characteristics may better identify individuals at risk of care avoidance for targeted interventions to mitigate financial toxicity.

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