Minding the Gap: Exploring the Impact of Structural Inequity and Adverse Social Determinants of Health on Hematopoietic Cell Transplant Access and Outcomes Público

Abstract

Introduction: While social determinants of health (SDoH) impact hematopoietic cell transplant (HCT) access in adult populations, there are limited data on this phenomenon in children. Using Fundamental Causes Theory, we hypothesized that children facing higher rates of structural inequity and adverse SDOH would receive HCT at lower rates than their peers facing less structural inequity.

Methods: This IRB-approved retrospective cohort study included children aged 0-21 with a hematologic malignancy or myelodysplastic syndrome (MDS) referred for first allogeneic HCT between January 1, 2015 and June 31, 2023. Data were abstracted from the electronic health record and address at referral was linked to the Social Vulnerability Index (SVI), Area Deprivation Index (ADI), and Childhood Opportunity Index (COI). Cox proportional hazard models were used to determine the association between SDoH and transplant receipt.

Results: Of 230 patients referred for HCT, 100 (43.5%) had acute lymphoblastic leukemia (ALL), 78 (33.9%) had acute myeloid leukemia (AML), and 29 (12.6%) had MDS. Sixty-three (27.5%) self-identified as Black, 60 (26.4%) self-identified as Hispanic, and 124 (54.2%) were insured through Medicaid. One hundred thirteen (49.1%) resided in low/very low COI areas and 62 (27.0%) resided in areas with a high/very high SVI. Seventy patients (30.4%) did not proceed to HCT. Of these individuals, 26 with ALL (68.4%) received alternative therapies including CAR-T, while 15 (83.3%) with AML died from disease progression or complications prior to HCT. There were no significant differences in HCT receipt based on age, sex, insurance, COI, or ADI. After adjusting for all significant variables found through univariable modeling, a high SVI at the national (HR 1.60, CI 1.06-2.41) and state level (HR 1.59, CI 1.06-2.38) remained factors associated with HCT receipt.

Conclusions: Contrary to our hypothesis, higher vulnerability, as proxied by the SVI, was associated with increased HCT receipt in children with hematologic malignancies and MDS. Pediatric patients may receive more comprehensive supports accounting for successful HCT in at-risk populations. Alternatively, patients from more vulnerable cohorts may be referred at lower rates or present with higher risk features that necessitate HCT over alternative therapies. To better understand these associations, prospective studies are warranted. 

Table of Contents

Distribution Agreement

Title Page

Table of Contents

Chapter 1: Introduction

1.1 Rationale

1.2 Theoretical Framework

1.3 Purpose Statement and Specific Aims

1.4 Significance

1.5 Definition of Terms

Chapter 2: Literature Review

2.1 Introduction

2.2 Pediatric Hematologic Malignancies and Myelodysplastic Syndromes

2.3 Pediatric Hematopoietic Cell Transplantation

2.4 Trends in Pediatric Hematopoietic Cell Transplantation

2.5 Social Determinants of Health and Pediatric Oncology

2.6 Social Determinants of Health and Hematopoietic Cell Transplantation

2.7 Gaps in Literature

2.8 Theoretical Framework

2.9 Conclusions

Chapter 3: Study Design, Recruitment, and Data Analysis

3.1 Study Design

3.2 Sampling and Recruitment

3.3 Data Collection

3.4 Data Analysis

3.5 Data Management

3.7 Positionality

Chapter 4: Manuscript

4.1 Abstract

4.2 Background

4.3 Methods

4.4 Results

4.5 Discussion

4.6 Tables and Figures

Chapter 5: Discussion, Public Health Implications, and Conclusions

5.1 Study Findings and Discussion

5.2 Public Health Implications

5.3 Conclusions

References

About this Master's Thesis

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School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Oncology
Palabra Clave	Social Determinants of Health
Committee Chair / Thesis Advisor	Kimberly Jacob Arriola PhD, MPH, Emory University
Committee Members	Michelle Schoettler MD, MSc, Emory University Staci Arnold MD, MBA, MPH, Emory University

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