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©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
Impact of payment source, referral site, and place of residence on outcomes after allogeneic transplantation in Mexico
Andrés Gómez-De León, Yesica A López-Mora, Valeria García-Zárate, Ana Varela-Constantino, Sergio U Villegas-De Leon, Xitlaly J González-Leal, Raúl del Toro-Mijares, Anna C Rodríguez-Zúñiga, Juan F Barrios-Ruiz, Victor Mingura-Ledezma, Perla R Colunga-Pedraza, Olga G Cantú-Rodríguez, César H Gutiérrez-Aguirre, Luz Tarín-Arzaga, Elías E González-López, David Gómez-Almaguer
Andrés Gómez-De León, Yesica A López-Mora, Valeria García-Zárate, Anna C Rodríguez-Zúñiga, Juan F Barrios-Ruiz, Victor Mingura-Ledezma, Perla R Colunga-Pedraza, Olga G Cantú-Rodríguez, César H Gutiérrez-Aguirre, Luz Tarín-Arzaga, David Gómez-Almaguer, Hematology Service, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José Eleuterio González, Monterrey 64460, Nuevo León, Mexico
Andrés Gómez-De León, Ana Varela-Constantino, Sergio U Villegas-De Leon, Xitlaly J González-Leal, Raúl del Toro-Mijares, Elías E González-López, David Gómez-Almaguer, Hematology Service, Clínica Gómez Almaguer, Monterrey 64710, Nuevo León, Mexico
Ana Varela-Constantino, Sergio U Villegas-De Leon, Xitlaly J González-Leal, Raúl del Toro-Mijares, Elías E González-López, Hematology Service, Instituto Tecnológico de Estudios Superiores de Monterrey, Tec Salud, Escuela de Medicina Ignacio Santos, Monterrey 64710, Nuevo León , Mexico
Author contributions: Gómez-De León A conceptualized the research, gathered and analyzed data, and wrote the paper; López-Mora YA wrote the paper; García-Zárate V gathered and analyzed data; Varela-Constantino A gathered data and wrote the paper; González-Leal XJ gathered and analyzed data; Del Toro-Mijares R gathered data and wrote the paper; Rodríguez-Zúñiga AC gathered and analyzed data; Barrios-Ruiz JF gathered and analyzed data; Mingura-Ledezma V gathered and analyzed data; Colunga-Pedraza PR analyzed data and wrote the paper; Cantú-Rodríguez OG wrote the paper; Gutiérrez-Aguirre CH analyzed data and wrote the paper; Tarín-Arzaga L wrote the paper; González-López EE gathered and analyzed data; Gómez-Almaguer D supervised the research, analyzed data, and wrote the paper.
Institutional review board statement: The study was reviewed and approved by the Research Ethics Committee of the University Hospital "Dr. José Eleuterio González" (Approval No. HE19-00018).
Informed consent statement: Due to the nature of the research, which involved either no risk or minimal risk to participants, it was determined with prior approval from the Ethics Committee that obtaining informed consent was not deemed necessary. The absence of potential harm or discomfort to the participants warranted this decision. As such, the study received a waiver of the informed consent form requirement.
Conflict-of-interest statement: All authors have no conflicts of interest to disclose.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at
dgomezalmaguer@gmail.com.
STROBE statement: The authors have read the STROBE Statement checklist, and the manuscript was crafted and edited in adherence to the items outlined in the STROBE Statement checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: David Gómez-Almaguer, FACP, MD, Professor, Hematology Service, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José Eleuterio González, Ave. Madero y Gonzalitos SN, Col. Mitras Centro, Monterrey 64460, Nuevo León, Mexico.
dgomezalmaguer@gmail.com
Received: December 20, 2023
Revised: January 29, 2024
Accepted: March 7, 2024
Published online: June 18, 2024
Processing time: 176 Days and 8.9 Hours
BACKGROUND
The impact of social determinants of health in allogeneic transplant recipients in low- and middle-income countries is poorly described. This observational study analyzes the impact of place of residence, referring institution, and transplant cost coverage (out-of-pocket vs government-funded vs private insurance) on outcomes after allogeneic hematopoietic stem cell transplantation (alloHSCT) in two of Mexico's largest public and private institutions.
AIM
To evaluate the impact of social determinants of health and their relationship with outcomes among allogeneic transplant recipients in Mexico.
METHODS
In this retrospective cohort study, we included adolescents and adults ≥ 16 years who received a matched sibling or haploidentical transplant from 2015-2022. Participants were selected without regard to their diagnosis and were sourced from both a private clinic and a public University Hospital in Mexico. Three payment groups were compared: Out-of-pocket (OOP), private insurance, and a federal Universal healthcare program “Seguro Popular”. Outcomes were compared between referred and institution-diagnosed patients, and between residents of Nuevo Leon and out-of-state. Primary outcomes included overall survival (OS), categorized by residence, referral, and payment source. Secondary outcomes encompassed early mortality, event-free-survival, graft-versus-host-relapse-free survival, and non-relapse-mortality (NRM). Statistical analyses employed appropriate tests, Kaplan-Meier method, and Cox proportional hazard regression modeling. Statistical software included SPSS and R with tidycmprsk library.
RESULTS
Our primary outcome was overall survival. We included 287 patients, n = 164 who lived out of state (57.1%), and n = 129 referred from another institution (44.9%). The most frequent payment source was OOP (n = 139, 48.4%), followed by private insurance (n = 75, 26.1%) and universal coverage (n = 73, 25.4%). No differences in OS, event-free-survival, NRM, or graft-versus-host-relapse-free survival were observed for patients diagnosed locally vs in another institution, nor patients who lived in-state vs out-of-state. Patients who covered transplant costs through private insurance had the best outcomes with improved OS (median not reached) and 2-year cumulative incidence of NRM of 14% than patients who covered costs OOP (Median OS and 2-year NRM of 32%) or through a universal healthcare program active during the study period (OS and 2-year NRM of 19%) (P = 0.024 and P = 0.002, respectively). In a multivariate analysis, payment source and disease risk index were the only factors associated with overall survival.
CONCLUSION
In this Latin-American multicenter study, the site of residence or referral for alloHSCT did not impact outcomes. However, access to healthcare coverage for alloHSCT was associated with improved OS and reduced NRM.
Core Tip: In our comprehensive analysis of allogeneic hematopoietic stem cell transplantation (alloHSCT) outcomes in Mexico, we underscore the pivotal role of insurance coverage. Patients with private insurance had superior survival rates compared to those relying on out-of-pocket or government programs. Intriguingly, geographical residence and referral sources did not significantly influence outcomes. This study underscores the profound implications of financial barriers in healthcare access and the urgent need for policy interventions. Our findings stress the importance of addressing socioeconomic disparities and emphasize the role of insurance status in enhancing alloHSCT outcomes in regions like Latin America.
