Assessing Post-Transplant Outcomes in Hematopoietic Stem Cell Recipients from Rural, Appalachian, and Medically Underserved Regions: Insights from a Single-Center Investigation

Introduction Hematopoietic stem cell transplant (HCT) treats several malignant and non-malignant conditions in pediatric patients. Survival and outcome disparities among adult HCT patients are associated with socioenvironmental factors. The impact of rurality, Appalachian residence, and medically underserved area (MUA) residence has not been fully examined in pediatric populations. Methods A retrospective chart review of children age ≤21 years receiving allogenic or autologous HCT between January 2012 and September 2022 at Nationwide Children's Hospital (NCH) was conducted. Survival status, relapse, admission length, appointment adherence, infections, complications requiring invasive intervention, and Graft-versus-host-disease were compared between geographic groups of interest. Rural/nonrural and Appalachian residence was coded using Rural Urban Commuting Areas (RUCA; Scale: 1-10; ≥4 was considered rural) and the Appalachian Regional Commission database, respectively. MUAs were designated based on the Health Resources and Services Administration's Office of Shortage Designation. Comparisons between geographic groups were stratified by transplant type and analyzed using nonparametric tests. P-values <0.05 were considered statistically significant. Results Of the 349 children investigated (62.8% allogenic, 37.2% autologous), 23.5% (n = 82) were rural, 18.6% (n = 65) were Appalachian, and 17.0% (n = 59) resided in a MUA. Appalachian allogenic transplant recipients were significantly more likely to experience relapse (40.0% vs. 16.3%; p = 0.001) and HCT failure (20.0% vs. 7.1%; p = 0.024) compared to non-Appalachian allogenic recipients. Similarly, children receiving allogenic transplant in MUAs were more likely to experience relapse (37.8% vs. 16.6%; p = 0.003) and death (37.8% vs. 17.1%; p = 0.005). Rural children receiving autologous transplant developed viral infections ≤100 days post-HCT (51.5% vs. 29.9%; p = 0.025) and bacterial infections ≤1 year post-HCT (51.5% vs. 24.7%; p = 0.004) more frequently than non-rural children. Conversely, non-Appalachian and non-MUA children undergoing autologous transplant developed viral infections ≤1 year post-HCT more often than Appalachian (25.0% vs 6.7%; p = 0.030) and MUA children (24.1% vs. 4.5%; p = 0.044). Conclusion Appalachian and medically underserved residency may be associated with increased rates of relapse following allogenic HCT. Additionally, Appalachian residency may be associated with HCT failure, while MUA residency may be associated with death post-allogenic HCT. Rural children undergoing autologous HCT may be at higher risk of infection post-HCT. Findings suggest further study is needed to understand the impact of rurality and underserved areas. Results may inform future opportunities for intervention during post-HCT care within these vulnerable populations.