Financial Toxicity and Its Determinants in Cardiovascular Diseases: A Systematic Review and Bayesian Meta-Analysis
Muhammed Shabil, Eswaran Maheswari, Amogh VermaIntroduction
Financial toxicity is an important but insufficiently synthesized dimension of cardiovascular disease burden, reflecting the economic hardship caused by out-of-pocket payments, indirect costs, medical debt, and affordability-related barriers to care.
Methods
A systematic review and Bayesian meta-analysis were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, Scopus, and Web of Science were searched up to May 2025 for studies evaluating financial toxicity among patients with cardiovascular diseases. Random-effects meta-analysis and Bayesian hierarchical models were used to estimate pooled prevalence, credible intervals, heterogeneity, and determinants of financial toxicity.
Results
Thirty studies including 1,087,594 patients were analyzed across diverse healthcare systems and cardiovascular conditions. Catastrophic health expenditure exceeding 40% of out-of-pocket spending affected 28% of patients in frequentist analysis and 34% in Bayesian analysis, while the 20% threshold affected 15%. Difficulty paying medical bills was reported by 46% of patients, and 16–17% were unable to meet medical expenses. Heterogeneity was substantial across outcomes, reflecting differences in healthcare financing, disease severity, and socioeconomic context. Consistent determinants of financial toxicity included lack of insurance, low income, rural residence, younger age, longer hospitalization, private-sector care, and procedurally intensive treatment.
Conclusion
Financial toxicity is highly prevalent among patients with cardiovascular diseases and is shaped by both socioeconomic vulnerability and healthcare system structure. Integrating financial risk screening, expanding insurance protection, reducing out-of-pocket expenditure, and targeting support toward high-risk groups are essential for improving equitable cardiovascular care.