Flannelly Colin, Tan Bryan E-Xin, Tan Jian Liang, McHugh Colin M, Sanapala Chandrika, Lagu Tara, Liesveld Jane L, Aljitawi Omar, Becker Michael W, Mendler Jason H, Klepin Heidi D, Stock Wendy, Wildes Tanya M, Artz Andrew, Majhail Navneet S, Loh Kah Poh
University of Massachusetts Medical School, Worcester, Massachusetts.
Department of Internal Medicine, Rochester General Hospital, Rochester, New York.
Biol Blood Marrow Transplant. 2020 Dec;26(12):2335-2345. doi: 10.1016/j.bbmt.2020.09.013. Epub 2020 Sep 20.
Hematopoietic cell transplantation (HCT) is an effective treatment for many hematologic malignancies, and its utilization continues to rise. However, due to the difficult logistics and high cost of HCT, there are significant barriers to accessing the procedure; these barriers are likely greater for older patients. Although numerous factors may influence HCT access, no formal analysis has detailed the cumulative barriers that have been studied thus far. We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to better categorize the barriers to access and referral to HCT, with a focus on the subgroup of older patients. We searched for articles published in English from PubMed, Embase, Cumulative Index for Nursing and Allied Health, and Cochrane Central Register of Controlled Trials between the database inception and January 31, 2020. We selected articles that met the following inclusion criteria: (1) study design: qualitative, cross-sectional, observational cohort, or mixed-method study designs; (2) outcomes: barriers related to patient and physician access to HCT; and (3) population: adults aged ≥18 years with hematologic malignancies within the United States. Abstracts without full text were excluded. QUALSYST methodology was used to determine article quality. Data on the barriers to access and referral for HCT were extracted, along with other study characteristics. We summarized the findings using descriptive statistics. We included 26 of 3859 studies screened for inclusion criteria. Twenty studies were retrospective cohorts and 4 were cross-sectional. There was 1 prospective cohort study and 1 mixed-method study. Only 1 study was rated as high quality, and 16 were rated as fair. Seventeen studies analyzed age as a potential barrier to HCT referral and access, with 16 finding older age to be a barrier. Other consistent barriers to HCT referral and access included nonwhite race (n = 16/20 studies), insurance status (n = 13/14 studies), comorbidities (n = 10/11 studies), and lower socioeconomic status (n = 7/8 studies). High-quality studies are lacking related to HCT barriers. Older age and nonwhite race were consistently linked to reduced access to HCT. To produce a more just health care system, strategies to overcome these barriers for vulnerable populations should be prioritized. Examples include patient and physician education, as well as geriatric assessment guided care models that can be readily incorporated into clinical practice.
造血细胞移植（HCT）是治疗多种血液系统恶性肿瘤的有效方法，其应用持续增加。然而，由于HCT的后勤保障困难且成本高昂，接受该治疗存在重大障碍；对于老年患者而言，这些障碍可能更大。尽管有许多因素可能影响HCT的可及性，但尚无正式分析详细阐述迄今为止所研究的累积障碍。我们按照系统评价和Meta分析的首选报告项目指南进行了一项系统评价，以更好地对HCT的可及性和转诊障碍进行分类，重点关注老年患者亚组。我们在PubMed、Embase、护理及相关健康累积索引和Cochrane对照试验中心注册库中检索了数据库建立至2020年1月31日期间以英文发表的文章。我们选择符合以下纳入标准的文章：（1）研究设计：定性、横断面、观察性队列或混合方法研究设计；（2）结局：与患者和医生接受HCT相关的障碍；（3）人群：美国年龄≥18岁的血液系统恶性肿瘤成年患者。排除无全文的摘要。采用QUALSYST方法确定文章质量。提取了HCT可及性和转诊障碍的数据以及其他研究特征。我们使用描述性统计总结了研究结果。在3859项经筛选符合纳入标准的研究中，我们纳入了26项。20项为回顾性队列研究，4项为横断面研究。有1项前瞻性队列研究和1项混合方法研究。只有1项研究被评为高质量，16项被评为中等质量。17项研究分析了年龄作为HCT转诊和可及性的潜在障碍，其中16项发现年龄较大是一个障碍。HCT转诊和可及性的其他一致障碍包括非白人种族（20项研究中的16项）、保险状况（14项研究中的13项）、合并症（11项研究中的10项）和社会经济地位较低（8项研究中的7项）。缺乏与HCT障碍相关的高质量研究。年龄较大和非白人种族一直与HCT可及性降低相关。为建立一个更公平的医疗保健系统，应优先考虑克服弱势群体这些障碍的策略。例如患者和医生教育，以及可轻松纳入临床实践的老年评估指导护理模式。
