Identification of Modifiable Factors Associated with Lower Adherence to Preventive Care Practices In HCT Survivors.
Authors: Khera Nandita , Chow Eric J. , Leisenring Wendy , Syrjala Karen L , Baker K. Scott , Flowers Mary E.D. , Martin Paul J. , Lee Stephanie J. 
Published: October 2019

Abstract
Abstract 3818
Although the adherence to recommended preventive care practices in hematopoietic cell transplantation (HCT) survivors is reported to be high, on average 25% of recommended preventive care is not delivered to this vulnerable population. We explored factors associated with lower adherence, with particular attention to modifiable factors, in a cross-sectional study of HCT long-term follow up (LTFU) patients. A 45- item supplementary module with questions about adherence to preventive care guidelines and financial concerns was added to the 236- item questionnaire that is mailed annually to LTFU patients who were alive at least 2 years after their first transplant in our center. 1550 (51%) of 3069 mailed questionnaires were returned. We have previously reported that the median adherence to recommended guidelines was 75%. Among other clinical and demographic factors associated with lower adherence, concern about medical costs and lack of knowledge about recommended tests emerged as major modifiable predictors. Of these respondents, 98% had medical insurance coverage, but 26% reported concerns about medical costs which were reflected by attempts to limit medical costs with one or more potentially deleterious avoidance behaviors (e.g., not taking a prescribed medicine, not having a medical test performed). Twenty-six percent worried that medical expenses would reach their lifetime limit. Only 27% of the respondents reported knowing recommended tests for transplant survivors, even though general guidelines are included with each annual questionnaire. 46% of the respondents indicated a desire to acquire this knowledge while 26% indicated that they relied on their treating physicians to be familiar with recommended guidelines. Multivariable logistic regression models were constructed for binary outcomes of “concerns about medical costs” and “lack of knowledge about recommended tests for LTFU patients” (Table). These models showed that concerns about medical costs were associated with lower physical and mental functioning, age less than 65 years, being female and not having chronic GVHD. Males, autologous transplant recipients, allogeneic transplant recipients who did not develop chronic GVHD, and patients surviving more than 15 years after HCT were more likely to report lack of knowledge about recommended tests for LTFU patients. When asked how they wished to receive information about recommended preventive care, patients favored mailed information (64%) over in-person evaluation (24%) or phone calls (27%). These results suggest that provision of comprehensive survivorship care plans might improve adherence to recommended preventive care practices by addressing lack of patient and provider knowledge. The increased support for preventive care by requiring health plans to cover preventive services and eliminating cost-sharing by the recent Affordable Care Act could also improve adherence by addressing financial concerns of this so-called ‘highly insured’ HCT LTFU population.
Table: Multivariable logistic regressions for concern about medical costs and lack of knowledge about recommended tests Outcome: Concern about Medical Cost Covariates OR (95% CI) p-valuea p-valueb Physical functioning < &minus;1 STD 2.70 (2.04,ü3.56) <0.001 Mental functioning < &minus;1 STD 2.31 (1.64, 3.26) <0.001 Age 65 or older 1.0 – <0.001 50–64.9 2.42 (1.57, 3.74) <0.001 40–49.9 3.99 (2.50, 6.37) <0.001 <40 3.14 (1.90, 5.20) <0.001 Male 0.63 (0.49, 0.82) <0.001 No chronic GVHD 1.41 (0.98, 2.01) 0.06 Outcome: Lack of knowledge about recommended tests for survivors Covariates OR (95% CI) p-value a p-value b Male 1.44 (1.15, 1.82) 0.002 No chronic GVHD 1.44 (1.05, 1.98) 0.03 Autologous transplant 1.68 (1.25, 2.25) 0.001 Time since Transplant  <5 years 1.0 – <0.001 5–9.9 years 0.97 (0.69, 1.36) 0.84 10–14.9 years 0.82 (0.57, 1.17) 0.27 15 years or more 1.72 (1.21, 2.46) 0.003 Abbreviations: STD = standard deviation, GVHD = graft versus host disease, OR = Odds Ratio, CI = Confidence Interval. a Category specific p-value from Wald test shown where different from overall variable level p-value. b Global p-value for covariate.

Disclosures:
No relevant conflicts of interest to declare.