Blood, Volume 137, 28 January 2021,
Social determinants of health, including poverty, contribute significantly to health outcomes in the United States; however, 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 database. We assembled 2 pediatric cohorts undergoing first allogeneic HCT from 2006 to 2015 at age ≤18 years, including 2053 children with malignant disease and 1696 children with nonmalignant disease. Neighborhood poverty exposure was defined a priori per the US 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 the time from HCT until death resulting from any cause. Secondary outcomes included relapse and transplantation-related mortality (TRM) in malignant disease, acute and chronic graft-versus-host disease, and infection in the first 100 days post-HCT. Among children undergoing transplantation for nonmalignant disease, neighborhood poverty was not associated with any HCT outcome. Among children undergoing transplantation for malignant disease, neighborhood poverty conferred an increased risk of TRM but was not associated with inferior OS or any other transplantation outcome. Among children with malignant disease, a key secondary finding was that children with Medicaid insurance experienced inferior OS and increased TRM compared with those with private insurance. These data suggest opportunities for future investigation of the effects of household-level poverty exposure on HCT outcomes in pediatric malignant disease to inform care delivery interventions.
Acute Graft Versus Host Disease; Acute Lymphoblastic Leukemia; Acute Myeloid Leukemia; Adolescent; Adult; Adult Respiratory Distress Syndrome; Adverse Event; Alemtuzumab; Allogeneic Hematopoietic Stem Cell Transplantation; Allotransplantation; Antineoplastic Agent; Article; Cancer Chemotherapy; Cause Of Death; Child; Child, Preschool; Chronic Disease; Chronic Graft Versus Host Disease; Chronic Myeloid Leukemia; Cohort Analysis; Comparative Study; Controlled Study; Cyclophosphamide; Cyclosporine; Databases, Factual; Economics; Ethnicity; Factual Database; Female; Follow Up; Follow-Up Studies; Graft Failure; Graft Versus Host Reaction; Graft Vs Host Disease; Health Care Delivery; Hematopoietic Stem Cell Transplantation; Hispanic; Hodgkin Disease; Human; Human Tissue; Humans; Infant; Infection; Infections; Insurance; Insurance Coverage; Interstitial Pneumonia; Major Clinical Study; Male; Malignant Neoplasm; Medicaid; Monozygotic Twins; Mortality; Myeloablative Conditioning; Myelodysplastic Syndrome; Neighborhood; Neoplasm; Neoplasms; Nonhodgkin Lymphoma; Outcome Assessment; Overall Survival; Poverty; Preschool Child; Priority Journal; Race; Recurrence; Recurrent Disease; Reduced Intensity Conditioning; School Child; Social Determinants Of Health; Survival Analysis; T Cell Depletion; Tacrolimus; Thymocyte Antibody; Transplantation, Homologous; Treatment Outcome; United States; Whole Body Radiation; Global