Impact of Socioeconomic Status, Race, and Insurance Payer on Outcomes following Allogeneic Hematopoietic Cell Transplantation.
BACKGROUND: Socioeconomic status (SES) and demographic variables have been demonstrated to influence treatment and outcomes across a wide range of health disciplines. The relationships between SES, race, insurance payer and outcomes following allogeneic hematopoietic cell transplantation (alloHCT), however, have not yet been clearly elucidated. To maximize the likelihood of treatment success, it is essential to determine the impact of these factors in alloHCT so that additional resources can be targeted to at-risk patients. Those patients who survive the initial period following alloHCT continue to be at risk for long-term complications such as graft-versus-host disease (GVHD), relapse, and secondary malignancies. OBJECTIVE: This study strives to determine the effect of SES, race, and insurance payer on survival outcomes following alloHCT at the University of California, San Francisco (UCSF). Our findings have the potential to influence recipient selection, housing and caretaker requirements following transplant, and the provision of means-based assistance for at-risk individuals. MATERIALS & METHODS: This retrospective single center study evaluated demographic and outcome data for all consecutive patients who received an alloHCT at UCSF between January 2012 and January 2016. Primary endpoints included progression free survival, relapse-related mortality, non-relapse mortality, overall survival, and the incidence and severity of GVHD. RESULTS: During the period of study, 252 patients underwent alloHCT. Amongst transplant recipients, 165 (65.5%) were Caucasian, 45 (17.9%) were Hispanic/Latino, 29 (11.5%) were Asian, 8 (3.2%) were African American, and 5 (2%) were Hawaiian/Pacific Islanders. Matched related donors were used for 98 (38.9%), unrelated donors for 138 (54.8%), haploidentical donors for 9 (3.6%), and umbilical cord blood for 6 (2.4%). Non-relapse mortality (NRM) was more common in non-Caucasian minorities versus Caucasians — 37% versus 31% of deaths in each group (HR 1.19). Based on median income by zip code of primary residence, patients were grouped into low income (<$55,000/yr) and high income (>$55,000/yr), and those in the low income group exhibited increased risk of NRM (HR 1.34). CONCLUSIONS: Our investigation demonstrated a trend toward increased NRM in non-Caucasian patients and in those with primary residences in low-income areas of Northern California. Additional investigation is underway to determine the influence of these and other variables, such as insurance payer and the use of philanthropic assistance such as grants-in-aid, on transplant-specific events such as GVHD, length of survival post-alloHCT, and causes of death in those who succumbed to non-relapse causes of death.