National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota.
National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota.
Transplant Cell Ther. 2021 Aug;27(8):685.e1-685.e8. doi: 10.1016/j.jtct.2021.04.009. Epub 2021 Apr 22.
Compared with 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 transplantation (alloHCT) outcomes among patients with sickle cell disease (SCD) is not well described. We sought to compare alloHCT outcomes between patients with SCD who underwent alloHCT while enrolled on Medicaid versus those who underwent alloHCT while covered by private health insurance. We conducted a retrospective multicenter study using data reported to the Center for International Blood and Marrow Transplant Research. US patients enrolled on Medicaid or private insurance who underwent 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 graft-versus-host disease (GVHD), and chronic GVHD. Univariate analysis was performed using the Kaplan-Meier method for EFS and OS. The proportion of patients with graft failure, acute GVHD, 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, and acute and chronic GVHD. A total of 399 patients (Medicaid, n = 225; private insurance, n = 174) were included in this study. The median duration of follow-up was 34 months (range, 1.0 to 134.7 months) for the Medicaid group and 38.7 months (range, 0.3 to 139.3 months) for the private insurance group. Compared with the patients with private insurance, those on Medicaid had a significantly lower 3-year EFS (75.4% [95% confidence interval (CI), 69.4% to 81%] versus 82.2% [95% CI, 76.9% to 87.8%]; P = .0279) and a significantly higher 3-year cumulative incidence of graft failure (17.2% [95% CI, 12.5% to 22.5%] versus 10.5% [95% CI, 6.4% to 15.4%]; P = .0372). There were no significant between-group differences in 3-year OS (P = .6337) or in the cumulative incidence of acute GVHD (P = .4556) or chronic GVHD (P = .6878). Cox regression analysis after adjusting for other significant variables showed that the patients enrolled on Medicaid had a lower EFS (hazard ratio [HR], 2.36; 95% CI, 1.44 to 3.85; P = .0006) and a higher cumulative incidence of graft failure (HR, 2.57; 95% CI, 1.43 to 4.60; P = .0015), with no significant between-group differences in OS (HR, 0.99; 95% CI, 0.47 to 2.07; P = .9765), acute GVHD (HR, 0.94; 95% CI, 0.59 to 1.49; P = .7905), or cGVHD (HR, 0.98; 95% CI, 0.65 to 1.48; P = .9331). That EFS is worse in patients on Medicaid compared with 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.
与私人保险患者相比，在几种临床情况下和接受各种手术及医疗程序后，医疗补助受助人的结局较差。然而，镰状细胞病（SCD）患者接受异基因造血细胞移植（alloHCT）后，健康保险状况与 alloHCT 结局之间的关系尚未很好描述。我们旨在比较 Medicaid 覆盖的 SCD 患者与私人健康保险覆盖的 SCD 患者接受 alloHCT 的结局。我们使用向国际血液和骨髓移植研究中心报告的数据进行了回顾性多中心研究。2008 年至 2018 年间接受首次 alloHCT 治疗 SCD 且登记在 Medicaid 或私人保险下的美国患者符合本研究条件。主要结局是无事件生存（EFS），定义为死亡或移植物衰竭的时间。次要结局包括总生存（OS）、移植物衰竭、急性移植物抗宿主病（GVHD）和慢性 GVHD。使用 Kaplan-Meier 法进行单变量分析以评估 EFS 和 OS。使用累积发生率估计来计算移植物衰竭、急性 GVHD 和/或慢性 GVHD 的患者比例，以适应竞争风险（即死亡）。使用 Cox 回归来确定与 EFS、OS、移植物衰竭以及急性和慢性 GVHD 相关的因素。本研究共纳入 399 例患者（Medicaid，n=225；私人保险，n=174）。Medicaid 组的中位随访时间为 34 个月（范围：1.0 至 134.7 个月），私人保险组为 38.7 个月（范围：0.3 至 139.3 个月）。与私人保险患者相比， Medicaid 患者的 3 年 EFS 显著较低（75.4%[95%置信区间（CI），69.4%至 81%]比 82.2%[95%CI，76.9%至 87.8%]；P=.0279），3 年累积移植物衰竭发生率显著较高（17.2%[95%CI，12.5%至 22.5%]比 10.5%[95%CI，6.4%至 15.4%]；P=.0372）。两组间 3 年 OS 无显著差异（P=.6337），急性 GVHD（P=.4556）或慢性 GVHD（P=.6878）的累积发生率也无显著差异。调整其他重要变量后的 Cox 回归分析显示， Medicaid 登记患者的 EFS 较低（风险比[HR]，2.36；95%CI，1.44 至 3.85；P=0.0006），移植物衰竭发生率较高（HR，2.57；95%CI，1.43 至 4.60；P=0.0015），但 OS 无显著差异（HR，0.99；95%CI，0.47 至 2.07；P=.9765），急性 GVHD（HR，0.94；95%CI，0.59 至 1.49；P=.7905）或慢性 GVHD（HR，0.98；95%CI，0.65 至 1.48；P=.9331）。在接受 alloHCT 治疗 SCD 的患者中， Medicaid 患者的 EFS 较差，这为研究提供了依据，以便更好地了解保险状况如何影响 SCD 患者的 alloHCT 结局。
