Race, Neighborhood Poverty and Medicaid Insurance Associated With Inferior Outcomes from Pediatric Hematopoietic Cell Transplantation for Malignant Disease

As the indications for hematopoietic cell transplantation (HCT) expand, understanding the impact of pre-transplantation disparities may help providers identify risk factors and inform interventions. This was the goal of a recent large, retrospective study, which found that neighborhood poverty, public insurance and race are associated with inferior outcomes from pediatric allogeneic HCT for malignant disease.

“There are several factors at play when it comes to outcomes from HCT, including the underlying disease, the type of transplant regimen used, and patient factors (that is, the social determinants of health),” says Navneet Majhail, MD, MS, Director of Cleveland Clinic’s Blood and Marrow Transplant Program and an author on the study. “This is one of the largest studies to look for an association between the social determinants of health and outcomes in pediatric patients who receive allogeneic HCT.”

Looking for associations between outcomes and social determinants of health

Using data from the Center for International Blood and Marrow Transplant Research, researchers assembled two cohorts of patients < 18 years old who underwent their first allogeneic HCT from 2006 through 2015: children with malignant disease (N = 2,053) and children with nonmalignant disease (N = 1,696). Neighborhood poverty was determined by the percentage of people in zip codes with household incomes below the federal poverty level. A high-poverty neighborhood had ≥ 20% of persons below 100% of the federal poverty level, while a low-poverty neighborhood had < 20% of persons below 100% of the federal poverty level.

“Since we used a national registry, our findings are generalizable. They give us a snapshot of what’s happening with pediatric HCT patients across the country,” notes Dr. Majhail.

The primary outcome was overall survival, which the team defined as the time from HCT until death from any cause. Secondary outcomes included relapse, transplantation-related mortality, acute and chronic graft-versus-host disease (GVHD), and infection in first 100 days post-HCT.

Race, neighborhood poverty and insurance affect outcomes in malignant cohort

In the non-malignant disease cohort, 288 children (13%) lived in high-poverty neighborhoods, and 597 (35%) of them had Medicaid insurance. Adjusted 5-year overall survival was 75%. There were no significant differences in overall survival, acute GVHD, chronic GVHD or infection based on neighborhood poverty level. There were no differences in primary or secondary outcomes based on insurance status, race or ethnicity in this cohort.

In the malignant disease cohort, 299 children (15%) lived in high-poverty neighborhoods, and 711 (35%) of them had Medicaid insurance. Adjusted five-year overall survival was 52%; transplantation-related mortality was 21%. Although there was no significant difference in adjusted five-year survival based on neighborhood poverty level, the rate of transplantation-related mortality (25%) was higher for those in high-poverty areas compared with those in low-poverty neighborhoods (20%). Children in high-poverty areas were more likely to experience organ failure as a cause of death (12%) than those in low-poverty areas (8%). Children with Medicaid insurance experienced a 23% increased risk of death compared to those with private insurance. Additionally, compared with White children, Black children had a 47% increased risk of death and a 65% increased risk of transplantation-related mortality.

“One of the most striking things about these results is that the patients included had all successfully accessed HCT. So, even when these patients get to transplant, there are some potentially modifiable or addressable health disparity issues that continue to contribute to outcomes,” says Dr. Majhail.

How much do zip codes tell us?

One weakness of this study is the use of zip codes in the determination of the neighborhood poverty levels, according to Dr. Majhail. There can be a whole spectrum of people of different races, ethnicities and income levels living within a single zip code. Having said that, Dr. Majhail points out that the use of zip codes is a well-validated research method. While it may not always be accurate at an individual level, on a population level zip codes tend to correlate fairly well with health disparities.

“The next steps in this area of study would be to better understand what tools can be used to get down to the individual level so that we might be able to tailor support services or better optimize their candidacy prior to transplant,” says Dr. Majhail.

“It is very important to address the impact of social determinants of health in pediatrics, as they have only emerged as a consideration in survival outcomes over the last decade,” notes Rabi Hanna, MD, Chair of the Department of Pediatric Hematology, Oncology and Blood & Marrow Transplantation at Cleveland Clinic Children’s. “We’re finding that things like race, socioeconomics and even distance from the treatment center all contribute to outcomes. Studies like this one help raise awareness; they help ensure that we’re paying attention to the whole patient—to the whole family. Right now we only see the tip of the iceberg, and it will be important to know more about the root causes so we can address these disparities and provide appropriate support to mitigate their effects if possible.”

The role of psychosocial assessment

Each patient who presents in need of a bone marrow transplant at Cleveland Clinic Children’s receives a psychosocial assessment. The goal is to assess social supports and uncover any other needs. Do they need grants to help with copays and deductibles? Is transportation an issue? If they are traveling for care, will local lodging, groceries or childcare be issues?

“Although we have this support system in place for our patients while they are under our care, some of these community health factors may come back into play again when they are discharged. This is an area of opportunity – identifying patients who need longer-term support and providing it as needed,” concludes Dr. Majhail.