Prevalence of Financial Toxicity and Its Association with Medication Adherence Among Patients Undergoing Haemodialysis Under Comprehensive Public Support in Japan

  1. Ryohei Inanaga
  2. Tatsunori Toida
  3. Tetsuro Aita
  4. Yusuke Kanakubo
  5. Mamiko Ukai
  6. Takumi Toishi
  7. Atsuro Kawaji
  8. Masatoshi Matsunami
  9. Tadao Okada
  10. Yu Munakata
  11. Tomo Suzuki
  12. Noriaki Kurita
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Abstract

Background and hypothesis

Financial toxicity (FT) refers not only to the difficulty in affording medical care but also to the psychological distress and perceived financial burden it imposes. Although dialysis in Japan is extensively covered by public insurance, little is known about the prevalence of FT and its effects on medication adherence. This study aimed to assess the prevalence of FT and examine its association with medication adherence among patients undergoing haemodialysis in Japan.

Methods

This multicentre, cross-sectional study included Japanese adults undergoing in-centre haemodialysis at six facilities. FT was assessed using the Comprehensive Score for Financial Toxicity (COST), and medication adherence was assessed using the 12-item Adherence Starts with Knowledge (ASK-12) scale. The COST scores were compared with published data from Japanese patients with cancer and patients undergoing dialysis from other countries using unpaired t-tests. Associations between the COST and ASK-12 scores were analysed using multivariate general linear models.

Results

In total, 455 participants were included in the analysis. The mean COST score was 22.0, and 68% of the participants experienced at least mild FT. FT severity was comparable to that of Japanese patients with cancer and significantly lower than that reported among patients undergoing dialysis in Brazil and China. Lower FT (i.e., higher COST scores) was associated with fewer medication adherence difficulties (per 1-point higher: β = –0.19). This association was particularly evident in the ‘inconvenience/forgetfulness’ and ‘behaviour’ subdomains (per 1-point higher: β = –0.06 and β = –0.08, respectively).

Conclusions

Despite generous public coverage, FT is common among Japanese patients undergoing haemodialysis and is associated with difficulties in medication adherence. The awareness of hidden financial distress and its integration into shared decision-making regarding prescriptions may help improve treatment adherence and patient outcomes.

Key learning points

What was known

  • Among patients undergoing dialysis, medication adherence rates are generally < 70%.

  • ‘Financial toxicity’ is associated with poor medication adherence in oncology.

  • However, among patients undergoing dialysis receiving publicly funded care, the prevalence of financial toxicity and its effects on medication adherence remain unclear.

This study adds

  • Despite Japan’s comprehensive public insurance system, approximately 70% of patients undergoing dialysis experience at least mild financial toxicity levels, comparable to those observed in Japanese patients with cancer.

  • Lower financial toxicity was associated with better medication adherence, particularly in the ‘inconvenience/forgetfulness’ and ‘behaviour’ subdomains.

Potential impact

  • Financial hardship can cause stress. Healthcare providers should build trust with their patients and foster open discussions on financial and social challenges.

  • Practising shared decision-making is essential for prescribing medications that consider patients’ financial burden.

  • Providing work-friendly dialysis schedules may support patients’ long-term financial independence.

Article activity feed

  1. Version published to 10.1101/2025.07.23.25332060 on medRxiv