Background Access to and outcomes after allogeneic hematopoietic cell transplantation (allo-HCT) have been previously associated with race and socioeconomic status (SES), mostly in registry or multicenter studies and with different results. Building on the racial and socioeconomic diversity of our institution's patient population, we retrospectively analyzed how race, individual- and area-level SES influenced transplant outcomes in a uniformly treated cohort.

Methods We reviewed 263 adult patients who underwent allo-HCT at the University of Illinois at Chicago between 2012–2023 for any diagnosis other than Sickle Cell Disease. Individual-level SES data included race, Medicaid status, employment, education, relationship status, and receipt of financial aid. Area-level SES indicators (linked to geocoded home address) included Area Deprivation Index (ADI), median household income, poverty rate, and Social Vulnerability Index (SVI), based on 2022 U.S. Census data. Outcomes analyzed included overall survival (OS), graft-versus-host disease-free relapse-free survival (GRFS), chronic GVHD (cGVHD), relapse, and non-relapse mortality (NRM). Demographic, transplant and socioeconomic characteristics were compared across racial groups and by Medicaid status using Chi-squared test or Kruskal-Wallis rank sum test. Kaplan-Meier and cumulative incidence methods were used for univariate analyses; Cox and Fine-Gray models for multivariable analysis.

Results The cohort was 43% non-Hispanic White, 21% non-Hispanic Black, 30% Hispanic, and 6% Asian. Medicaid was the primary insurer for 52% of patients; 57% received financial aid. Racial minorities had significantly higher unemployment, Medicaid use, and worse area-level SES indicators (e.g., higher SVI, lower income). Despite these disparities, race was not associated with OS, GRFS, NRM, or relapse. Medicaid status was associated with a higher incidence of cGVHD (p=0.02), but not with OS, GRFS, relapse, or NRM. The 1-year cumulative incidence (CI) of cGVHD was 28% for the Medicaid group compared to 19% for the non-Medicaid group. Among area-level SES variables, poverty rate and SVI were associated with higher cGVHD incidence and worse GRFS, but not with OS or NRM (1-year CI: 34% vs 21% for poverty rate; 1-year CI: 32% vs 22% for SVI). In multivariate analysis, Medicaid remained independently associated with higher risk of cGVHD (HR 1.71; p=0.039).

Conclusions In this diverse single-center cohort, race and SES were not associated with survival outcomes after allo-HCT, reflecting equitable care delivery. However, SES disadvantage, particularly Medicaid status, higher poverty, and social vulnerability, was linked to increased cGVHD risk, possibly reflecting challenges with treatment adherence or access to follow-up care. These findings underscore the need for targeted support strategies in socially vulnerable patients and highlight the importance of using both individual- and area-level SES data for better patient characterization.

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2025
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