Patient Socioeconomic Status Impacts Long-Term Outcomes After Allogeneic Hematopoietic Cell Transplant

Transplant survivors with low socioeconomic status have a heightened risk of complication-related mortality after allogeneic hematopoietic cell transplantation, according to a study conducted between 2003 and 2012 at Cleveland Clinic.

The study identifies a population that may be disadvantaged because of barriers in access to healthcare. The researchers propose more studies on the topic to improve understanding of the complicated problem and to help identify better interventions.

The investigators are presenting their findings at the 2015 BMT Tandem Meetings in San Diego. The presentation, “Socioeconomic Status Influences Long-Term Outcomes in 1-Year Survivors after Allogeneic Hematopoietic Cell Transplantation,” provides an overview of the methodology and outcomes of the research.

Study Design

Low socioeconomic status (SES) has been shown to be associated with healthcare disparities, including poor access and adverse outcomes, in patients with a variety of medical conditions. Allogeneic hematopoietic cell transplantation (allo HCT) recipients are already at risk for long-term mortality from late complications.

“Although early post-transplant care is typically well-coordinated through the patient’s transplant center, as patients transition back to their community providers, we believed it was possible that those with fewer resources and poor access to health care would be at higher risk for complications and mortality,” says Cleveland Clinic Fellow Shuang Fu, MD, who will be presenting the study results at the conference. “Therefore, we hypothesized that socioeconomic status would be associated with survival and non-relapse mortality in long-term survivors after allo HCT.”

Researchers studied 283 consecutive allo HCT recipients transplanted between 2003 and 2012 who had survived for at least one year in remission. Median annual household income was estimated using census tract data and the ZIP code of residence at the time of transplant. SES categories were determined by recursive partitioning analysis and were categorized into low SES (< $51,000/yr., N = 203) and high SES (≥ $51,000/yr., N = 80). Low SES patients were more likely to be non-white (10 percent vs. 1 percent); otherwise there were no notable differences between the two cohorts.

Study Results

In univariate analysis, low SES patients had significantly worse survival and non-relapse mortality (NRM) rates but a comparable incidence of relapse mortality. In multivariate analyses that adjusted for patient, disease and transplant characteristics, patients with low SES had significantly higher risks of all-cause mortality and NRM, but similar risks of relapse mortality compared with high SES patients.

“Our study highlights socioeconomic disparities among long-term allogeneic hematopoietic cell transplant survivors,” says Navneet Majhail, MD, Director of Cleveland Clinic’s Blood & Marrow Transplant Program and a co-author of the study. “Patients with a higher socioeconomic status have significantly better overall survival and lower non-relapse mortality compared with those from lower socioeconomic strata. Preliminary data from our study suggest that these disparities are accentuated in patients with chronic graft-versus-host disease, a transplant complication which can by itself cause substantial morbidity and needs intensive coordinated treatment and followup.”

Future Research Goals

Causes of healthcare disparities are complex, but the findings from Cleveland Clinic’s study identify a high-risk population that may be disadvantaged due to barriers to healthcare access.

“Poor survival was primarily driven by a higher risk of transplant complication-related mortality, while there was no difference in the risks for relapse-related mortality,” says Dr. Majhail. “This study lays the foundation for more research in this area. Additional studies are needed to better understand socioeconomic disparities in allogeneic transplantation and interventions to mitigate them.”