A Tale of Two Centers: Access to Private Care Improves Outcomes in Allogeneic Transplant Recipients

Introduction

Allogeneic bone marrow transplantation (BMT) is a potentially curative treatment for many hematological diseases. However, lack of availability of specialized centers and high costs limit access to the procedure in low and middle income countries. Previous research has shown that Latin-American patients with hematological malignancies have worse outcomes when treated in public health systems compared to patients treated in the private setting. Healthcare in Mexico is provided by three systems: the private sector (financed by a private insurance or out of pocket), social security (government-run health systems) and a public system (partially funded by the government), where the most vulnerable population is treated. To date, disparities in outcomes of BMT between patients in public and private health systems have not been widely studied.

Objectives

Primary: to determine the impact of access to private healthcare in BMT recipients by comparing the outcomes of patients treated in two centers that are led by a single team. Secondary objectives were to determine differences in the overall treatment population and transplantation strategies in each context.

Patients and Methods

We performed a retrospective analysis of consecutive patients aged 15 and older who underwent BMT regardless of diagnosis form 2015-2021 in two Institutions: 1) A private hematology practice treating insured patients in conventional BMT units similar to those in high-income countries (Private) and 2) A public academic institution where an outpatient transplant strategy is common in the context of significant limitations in access to quality supportive care and high-cost medications (Public). Both programs are led by the same team of hematologists following similar transplant strategies with the salient features being the frequent use of peripheral blood stem cells, chemotherapy-based conditioning regimens, and the preferred use of haploidentical donors vs. matched unrelated donors. We excluded second transplants from this analysis and patients who received them were censored at the time of infusion. We compared baseline characteristics, overall survival (OS), event free survival (EFS), non-relapse mortality (NRM), and the incidence of GVHD in the two different treatment systems.

Results

A total of 219 patients underwent BMT from January 2015 to June 2021, n=166 (76%) were performed in the Public setting, and n=53 (24%) in the Private setting. Patients in the Private group were older, with a higher proportion of high/very high disease risk index (DRI), hematopoietic cell comorbidity index (HCT-CI) and more frequent use of myeloablative conditioning (Table 1). A similar proportion haploidentical donor grafts were performed (61 vs 57%) with a single matched unrelated donor transplant in the Private center. Median follow-up was 9.7 (0.2-71), and 10.3 (0.7-67.6) months, for Public and Private centers respectively (p=0.38). Median time to neutrophil and platelet engraftment were similar. Seventy patients (42%) in Public, and 15 patients (28%) in Private groups relapsed (p=0.049), with a median time to relapse of 17.5 vs. 47.6 months (p<0.017); there were no significant differences in non-relapse mortality at 2 years (27 vs. 18%) (Fig.1) and primary failure (9% vs 2%). Grade 2-4 aGVHD occurred in 31% patients in the Public setting vs. 19% in Private (p=0.08), without differences in grade 3-4 aGVHD (12% vs 8%). Moderate/severe cGVHD incidence was similar for both groups with (19 vs. 18%). Estimated 2-year EFS was 34% in Public vs. and 54% in Private (Fig. 2), with a median EFS of 8.8 vs 25.7 months (p= 0.024). There were no statistically significant differences in OS (p=0.65), with estimated 2-year OS of 51% for Public and 68% for Privately treated patients, and a median OS of 21.1 months vs. not reached (Fig. 3). When stratified by DRI, patients with Public BMT and a high/very high DRI had a median OS of only 9.7 months vs. not reached for the Private group (Fig. 4). Patients with high/very high DRI in the Private setting had similar outcomes to those with low/intermediate disease in the Public group with the best outcomes achieved by patients with low/intermediate disease treated privately.

Conclusion

Patients who undergo BMT in the public health system are at risk for significantly worse outcomes when compared to patients cared for in private systems even if a similar strategy is followed and are led by the same team.

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