Neighborhood poverty and pediatric allogeneic hematopoietic cell transplantation outcomes: a CIBMTR analysis

Abstract

Social determinants of health, including poverty, contribute significantly to health outcomes in the United States, yet their impact on pediatric hematopoietic cell transplantation (HCT) outcomes is poorly understood. We aimed to identify the association between neighborhood-poverty and HCT outcomes for pediatric allogeneic HCT recipients in the Center for International Blood and Marrow Transplant Research (CIBMTR) database. We assembled two pediatric cohorts who received a first, allogeneic HCT from 2006-2015 at age ≤18 years; including 2053 children with malignant disease and 1696 children with non-malignant disease. Neighborhood-poverty exposure was defined a priori per U.S. Census definition as living in a high-poverty ZIP code (>=20% of persons below 100% Federal Poverty Level) and used as the primary predictor in all analyses. Our primary outcome was overall survival (OS) defined as time from HCT until death from any cause. Secondary outcomes included relapse and transplant-related mortality (TRM) in malignant disease, acute and chronic GVHD, and infection in the first 100 days post-HCT. Among children transplanted for non-malignant disease, neighborhood-poverty was not associated with any HCT outcome. Among children transplanted for malignant disease, neighborhood-poverty conferred an increased risk of TRM but was not associated with inferior OS or any other transplant outcome. Among children with malignant disease, a key secondary finding was that children with Medicaid insurance experienced inferior OS and increased TRM compared to those with private insurance. These data suggest opportunities for future investigation of household-level poverty exposures on HCT outcomes in pediatric malignant disease to inform care delivery interventions.

Parental limited English proficiency in pediatric stem cell transplantation: Clinical impact and health care utilization

“…The parental LEP group was more likely to self‐identify as having financial strain at the time of pretransplant evaluation and these children were more likely to have government‐sponsored Medicaid, both of which suggest likely differences in socioeconomic status. A large pediatric transplant database analysis recently demonstrated inferior overall survival in children with Medicaid as compared to children with private insurance among pediatric patients receiving allogeneic transplant for malignant diseases 49 …”

Social determinants of health and pediatric cancer survival: A systematic review

“…For patients with unspecified malignant disease who received hematopoietic cell transplant treatment, those on public insurance (Medicaid) had higher probability of all-cause mortality. 36 Some studies found no association between insurance and survival.…”

Social determinants of health and primary immunodeficiency

“…The disparity between malignant and nonmalignant conditions is intriguing, and possibly a result of a selection bias in the nonmalignant cohort, in which often HSCT is not the first-line treatment option. 111 In the posttransplant period, 34% of patients with long-term graft-vs-host disease had experienced delayed/denied treatments for their condition contributing to their financial hardship. 112 A multidisciplinary approach including psychosocial and sociodemographic assessments can help mitigate these challenges.…”