Health Disparity in Hematopoietic Cell Transplantation for Sickle Cell Disease: Analyzing the Association of Insurance and Socioeconomic Status Among Children Undergoing Hematopoietic Cell Transplantation

OBJECTIVE: The impact of racial and socioeconomic status (SES) on access to hematopoietic cell transplantation (HCT) are well known. Even when controlled for SES, racial minorities have lower access to HCT than the racial majority groups. Since the majority of patients with sickle cell disease (SCD) in the US are of African descent, HCT for SCD provides a unique opportunity to study the impact of SES on access to HCT in a relatively uniform racial population. The objectives of this study were to explore whether insurance status and SES are associated with the HCT for SCD.

METHODS: The clinical database from the SCD program at Children's Healthcare of Atlanta (CHOA), which contains over 3,100 patients, was used to identify SCD patients who have undergone HCT between January 1, 2012 and December 31, 2016 at CHOA. We then identified non-transplanted SCD patients matched for age at transplant, gender, and SCD genotype. Three matched controls were randomly selected for each case except for one older patient who only had two controls. Non-Georgia residents during the year of transplant were excluded; one sickle cell patient who had BMT due to acute lymphoblastic leukemia was also excluded. Among both the transplanted patients and their controls, insurance status was assessed as well as socioeconomic status was estimated based on block-level census data, specifically household income, home value, percent single parent households, percent unemployment, and education level. Conditional logistic regression analysis using backwards elimation was performed to determine the odds of receiving HCT.

RESULTS: Of 34 patients with SCD who underwent HCT at CHOA during this time period, 27 (66.7% females and 33.3% males) were Georgia residents. Twenty-five of the 27 patients received a matched-sibling donor transplant and two had matched-unrelated donor transplant. Among the HCT patients, the median age at transplant was 8 ± 4.7 years (range 1-20 yr). Of the 27 HCT patients, 59.3% had Medicaid and 40.7% had Private insurance at the time of transplant. Among the controls, 81.3% were covered by Medicaid insurance, 17.5% with Private insurance, and 1.3% self-pay. Using a conditional logistic regression model, we found insurance status to be a statistically significant factor in predicting whether a patient undergoes HCT. The model showed that those with Private Insurance are 2.96 (95% Confidence Interval: 1.02, 8.54) times more likely to undergo HCT compared to patients with Medicaid and self-pay. No other socioeconomic status variables were associated with receiving HCT.

CONCLUSION: The data suggest that there may be health disparities in the application of HCT for SCD and that SCD patients who have private insurance are more likely to undergo HCT than those with Medicaid insurance. Important limitations of this study include absence of information about the availability of matched-sibling donors among the non-transplanted patients. A more detailed analysis of the impact of disease severity on the application of HCT for SCD is warranted. Similarly, these data provide the rationale for a larger study of national trends on the impact of the type of insurance and SES on access to HCT for SCD as well as factors that may be contributing to this health disparity.