Barriers to Hematopoietic Cell Transplantation for Adults in the United States: A Systematic Review with a Focus on Age

Author Department

Healthcare Quality

Document Type

Article, Peer-reviewed

Publication Date

9-2020

Abstract

Introduction: Hematopoietic cell transplantation (HCT) is an effective treatment for many hematological malignancies, and its utilization continues to rise. However, due to the difficult logistics and high cost of HCT, there are significant barriers to accessing the procedure; these barriers are likely greater for older patients. Although numerous factors may influence HCT access, no formal analysis has detailed the cumulative barriers that have been studied thus far.

Methods: We conducted a systematic review following PRISMA guidelines to better categorize the barriers to access and referral to HCT, with a focus on the subgroup of older patients. We searched for articles published in English from PubMed, Embase, Cumulative Index for Nursing and Allied Health (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) between the database inception and January 31st, 2020. We selected articles that met the following inclusion criteria: 1) Study design: qualitative, cross-sectional, observational cohort, or mixed-method study designs; 2) Outcomes: barriers related to patient and physician access to HCT; 3) Population: adults aged ≥18 years with hematological malignancies within the US. Abstracts without full text were excluded. QUALSYST methodology was used to determine article quality. Data on the barriers to access and referral for HCT were extracted, along with other study characteristics. We summarized the findings using descriptive statistics.

Results: We included twenty-six of 3,859 studies screened for inclusion criteria. Twenty studies were retrospective cohorts and four were cross-sectional. There was one prospective cohort study and one mixed method study. Only one study was rated as high-quality and 16 were rated as fair. Seventeen studies analyzed age as a potential barrier to HCT referral and access with sixteen finding older age to be a significant barrier. Other consistent barriers to HCT referral and access included non-white race (n=17/20 studies), insurance status (n=12/14 studies), comorbidities (n=10/11 studies), and lower socioeconomic status (n=7/8 studies).

Conclusions: High-quality studies are lacking related to HCT barriers. Older age and non-white race were consistently linked to reduced access to HCT. To produce a more just healthcare system, strategies to overcome these barriers for vulnerable populations should be prioritized. Examples include patient and physician education, as well as geriatric-assessment guided care models that can be readily incorporated into clinical practice.

Keywords: Barriers; age; hematopoietic cell transplantation; race.

PMID

32961375

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