SKIN January 2023 Volume 7 Issue 1 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 581 Research Letter Financial Burden of Parking Fees for Phototherapy Patients: A Cross-Sectional Study Kyaw Zin Htet, BA1, Theresa Bui, BS1, Apurv Srivastav, MS2, Andrea Murina, MD3, Drew Kuraitis, MD, PhD3,4 1Tulane University School of Medicine, New Orleans, LA 2Division of Biostatistics, University of California, Davis, CA 3Department of Dermatology, Tulane University School of Medicine, New Orleans, LA 4Department of Dermatology, Roswell Park Comprehensive Cancer Center, Buffalo, NY Narrow band UVB phototherapy is a common treatment for many dermatologic conditions. Although, it is often covered by insurance or by safety net hospitals, there may still be significant treatment-associated parking costs as patients frequently require multiple sessions per week at a designated clinical site. Parking fees for cancer patients can approach thousands of dollars annually, posing a barrier for financially disadvantaged patients.1 This cross-sectional study aimed to assess parking fees associated with phototherapy across the United States and to investigate geographic associations with cost of living and transit access. Clinical sites were identified as those affiliated with U.S academic dermatology residency programs. The following information for each site was ascertained via phone calls and online search, if available: phototherapy center address, transit score, city cost of living score, public transit information, parking rates and reimbursement for phototherapy patients (supplemental methodology available at https://data.mendeley.com/datasets/376wv4 4c9b/1). Mean, median, and range of each score and cost were calculated, and a Spearman correlation was calculated for two variables. Of 343 identified clinical sites, 314 responded while 29 did not respond. Of the 314 participant sites, 69 sites did not offer phototherapy services, and 6 sites did not have on-site parking. Full information (parking costs, city cost of living and transit score) was only available for 177 sites (Table 1). Of the sites with full available information, 124 (124/177; 70.1%) offered free or validated parking for all patients, and 65 (65/177; 36.7%) have public transportation information available on their website. Hourly parking costs were associated with transit score (Fig. 1A; r= 0.241, p=.0004) and city cost of living (Fig. 1B; r=0.207, p=0.006). Parking fees represent significant nonmedical financial barrier to patients undergoing phototherapy treatment, especially if multiple times per week. In our study, 8.5% (29/343) of phototherapy sites did not detail parking fees on their websites nor provide such information via telephone inquiry. This can lead to unexpected financial costs related to medical treatment which in turn could lower patients’ willingness to pay for care.2 We also found that cities with a https://data.mendeley.com/datasets/376wv44c9b/1 https://data.mendeley.com/datasets/376wv44c9b/1 SKIN January 2023 Volume 7 Issue 1 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 582 Table 1. Transit score, transit score correlations with/without free parking and with/without public transportation information online, city cost of living score, city cost of living score correlations with/without free parking and with/without public transportation information online and, parking costs. Abbreviation: IQR = Interquartile Range. a The transit score range is from 0-10, with 0-3 indicating minimal transit options and 8-10 indicating efficient and accessible transportation. b The city cost of living was indexed to 100, with 100 being the average cost of living and index values above 100 indicate that the city has a cost living above the average, while values below 100 indicate a cost of living below the average. cThe n value represents the clinical sites with full information available for analysis (parking costs, city cost of living and transit score) dThe n value represents the clinical sites that charges parking fees for patients Variable n Mean  SD Median (IQR) Range, low- high T test (p value) Phototherapy center address transit scorea 177c 7.99  2.05 8.50 (7.10 - 9.60) 0.00 – 10.00 - Phototherapy center address transit score in sites with free parking 132 7.77  2.13 8.30(7.10 – 9.30) 0.00 – 10.00 0.0004 Phototherapy center address transit score in sites without free parking 45 8.61  1.69 9.50 (8.20 – 9.70) 1.50 – 10.00 Phototherapy center address transit score with public transportation information online 112 7.66  2.04 8.20(7.00 – 9.20) 0.00 – 9.90 0.0049 Phototherapy center address transit score without public transportation information online 65 8.55  1.97 7.30 (8.30 – 9.70) 1.50 – 10 City cost of living score 177c 108.1  19.19 102.00 (93.70 - 118.70) 87.30 – 183.00 - City cost of living score in sites without free parking 132 106.0  17.71 100.30 (93.50 – 110.5) 87.30 – 183.00 0.0057 City cost of living score in sites with free parking 45 114.3  22.06 105.30 (96.9 – 128.0) 88.20 – 183.00 City cost of living score in sites without public transportation information online 112 104.9  16.53 100.25 (93.42 – 108.20) 90.07 – 183.00 0.0033 City cost of living score in sites with public transportation information online 65 113.6  22.13 105.3 (95.8– 128.0) 87.30 – 181.10 Cost of parking, $ Hour 53d 5.10  5.55 4.00 (2.00 – 5.00) 0.00 – 26.00 - Day 53d 12.7  9.22 10.0 (6.0 – 15.0) 0.00 – 44.00 - SKIN January 2023 Volume 7 Issue 1 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 583 Figure 1A & B. Pearson Correlations Between Transit Score and City Cost of Living with Hourly Parking Costs. Each plotted dot represents a medical center that offer phototherapy services. Abbreviation: d = day. Hourly parking costs were associated with transit scores (Fig 1A; r= 0.241, p=.0004) and cost of living (Fig 1B; r=0.207, p=0.006). SKIN January 2023 Volume 7 Issue 1 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 584 higher cost of living do not have as much free parking, compounding financial barriers. The average median parking cost in our study was $5.10, amounting to $798.15 annually for thrice weekly therapy. Home phototherapy units range from $900 to $1500 and can be more cost-effective given similar clinical efficacy to office-based phototherapy and elimination of non-medical costs such as parking fees.3,4 As inconvenience and therapy-associated costs are lead reasons for patient discontinuation of phototherapy, home unit provision should be pursued in an effort to reduce long-term costs and improve patient adherence.5 For patients requiring in- office phototherapy, clinical sites should offer validated or free parking to eliminate non- medical financial barriers. Study limitations include limited number of sites that were available for data collection, as those that could not be reached through website and/or telephone as well as those without full information from data sources were not included in the study. Our study sample was limited to academic/teaching centers and thus may not be representative of all sites offering phototherapy. There could also be inaccuracy of costs that were collected through website and/or telephone, as websites and site staff may not have updated information available. Phototherapy remains a first-line treatment modality for various dermatological conditions, given its great efficacy, high tolerability and low cost profile. With an increase usage of phototherapy services among Medicare and Medicaid beneficiaries, it is important for clinicians to be aware of non-medical costs such as parking fees that could further contribute to the health disparities of the population.6 Conflict of Interest Disclosures: None Funding: None Corresponding Author: Drew Kuraitis, MD, PhD 1430 Tulane Avenue #8036 Phone: (504) 988-5114 Email: dkuraiti@tulane.edu References: 1. Lee A, Shah K, Chino F. Assessment of Parking Fees at National Cancer Institute- Designated Cancer Treatment Centers. JAMA Oncol. Aug 1 2020;6(8):1295-1297. doi:10.1001/jamaoncol.2020.1475 2. Chino F, Peppercorn JM, Rushing C, et al. Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care. JAMA Oncol. Nov 1 2017;3(11):1582-1584. doi:10.1001/jamaoncol.2017.2148 3. Jacob J, Pona A, Cline A, Feldman S. Home UV Phototherapy. Dermatol Clin. Jan 2020;38(1):109-126. doi:10.1016/j.det.2019.09.001 4. Lim HW, Silpa-archa N, Amadi U, Menter A, Van Voorhees AS, Lebwohl M. Phototherapy in dermatology: A call for action. J Am Acad Dermatol. Jun 2015;72(6):1078-80. doi:10.1016/j.jaad.2015.03.017 5. Yentzer BA, Feldman SR. Trends in home phototherapy adoption in the US: monetary disincentives are only the tip of the iceberg. J Dermatolog Treat. Feb 2011;22(1):27-30. doi:10.3109/09546630903440080 6. Tan SY, Buzney E, Mostaghimi A. Trends in phototherapy utilization among Medicare beneficiaries in the United States, 2000 to 2015. J Am Acad Dermatol. Oct 2018;79(4):672-679. doi:10.1016/j.jaad.2018.03.018