Hematopoietic Cell Transplant Outcomes among Medicaid and Privately Insured Patients with Sickle Cell Disease

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Transplant Cell Ther. 2021 Apr 22:S2666-6367(21)00856-3. doi: 10.1016/j.jtct.2021.04.009. Online ahead of print.


BACKGROUND: Compared to privately insured patients, recipients of Medicaid have been reported to have worse outcomes in several clinical conditions and following various surgical and medical procedures. However, the relationship between health insurance status and allogeneic hematopoietic cell transplant (alloHCT) outcomes among patients with sickle cell disease (SCD) is not well described.

OBJECTIVE: We sought to compare alloHCT outcomes among patients with SCD who received an alloHCT while enrolled on Medicaid versus private health insurance.

STUDY DESIGN: We conducted a retrospective multicenter study utilizing data reported to the Center for International Blood and Marrow Transplant Research. US patients enrolled on Medicaid or private insurance, who received a first alloHCT for SCD between 2008 and 2018 were eligible for this study. The primary outcome was event-free survival (EFS), defined as time to death or graft failure. Secondary outcomes included overall survival (OS), graft failure, acute and chronic graft-versus-host disease (GVHD). Univariate analysis was performed using Kaplan-Meier Method for EFS and OS. The proportion of patients with graft failure, acute and/or chronic GVHD was calculated using the cumulative incidence estimator to accommodate competing risks (ie, death). Cox regression was used to identify factors associated with EFS, OS, graft failure, acute and chronic GVHD.

RESULTS: A total of 399 patients (Medicaid: 225; private insurance: 174) were included in this study. The median follow-up was 34 months (range 1.0-134.7) and 38.7 months (range 0.3-139.3) for patients enrolled on Medicaid and private insurance, respectively. Patients on Medicaid compared to private insurance had significantly lower 3-year EFS 75.4 (95%CI: 69.4-81)% vs. 82.2 (95%CI: 76.9-87.8)%, p= 0.0279 and significantly higher 3-year cumulative incidence of graft failure 17.2 (95%CI: 12.5-22.5)% vs. 10.5 (95%CI: 6.4-15.4)%, p= 0.0372. There were no significant differences in 3-year OS p= 0.6337, the cumulative incidence of aGVHD p=0.4556 or cGVHD p=0.6878 between the two groups. Cox-regression analysis, adjusting for other significant variables showed that patients enrolled on Medicaid compared to private insurance had lower EFS (hazard ratio (HR): 2.36, 95% CI: 1.44-3.85; p= 0.0006) and higher cumulative incidence of graft failure (HR: 2.57, 95% CI: 1.43-4.60; p=0.0015 with no significant difference in OS (HR: 0.99, 95% CI: 0.47-2.07; p=0.9765); aGVHD (HR: 0.94, 95% CI: 0.59-1.49; p=0. 7905), or cGVHD (HR: 0.98, 95 CI: 0.65-1.48; p=0.9331).

CONCLUSION: That EFS is worse in patients with Medicaid as compared to privately insured individuals following alloHCT for SCD provides the rationale for research to better understand the mechanisms by which insurance status impacts alloHCT outcomes among patients with SCD.

PMID:33895405 | DOI:10.1016/j.jtct.2021.04.009