Household Material Hardship and Inpatient Days in Dana-Farber Cancer Institute (DFCI) Acute Lymphoblastic Leukemia (ALL) Consortium Trial 16-001

Introduction: Pediatric cancer-related hospitalizations are long and costly, with significant psychosocial and financial implications for children and families, and financial ramifications for payors (Price 2006). Among general pediatric populations, poverty-exposed children experience disparities in healthcare utilization, including longer hospital length of stay (LOS) (McKay and Parente 2019) (Andrist 2019). While poverty-exposed children with acute lymphoblastic leukemia (ALL) experience well-defined disparities in relapse and survival (Bona 2016), it is not known if similar inequities in hospitalization during frontline trial-delivered treatment exist. Identification of modifiable poverty exposures associated with disparities in healthcare utilization is key to promoting equity in childhood ALL care delivery. We evaluated the association between household material hardship ([HMH], food, housing, and/or utility insecurity) and inpatient days among trial-enrolled children with ALL.

Methods: A prospective, opt-in, cohort study among US children ages 1-<18 years with de novo B- or T-cell ALL was conducted as an embedded component of DFCI ALL Consortium trial 16-001 (NCT03020030). Participants were enrolled at 6 US centers from 2017-2021. Parent/guardian-reported HMH data were collected by day 32 of Induction and categorized as HMH-exposed (at least 1 resource insecurity) vs. unexposed (no resource insecurity). Total number of hospitalization days from trial enrollment through 6-months were abstracted from the medical record. Multivariable quantile regression was utilized due to skewed outcome distribution and models evaluated associations between HMH-exposure and inpatient days adjusted for sex and trial-defined final risk-treatment group (low-risk [LR], intermediate/high-risk [IR/HR], and very high-risk [VHR]).

Results: The cohort included 274 children, 49% female with a mean age of 7.2 years (SD: 4.5). Eighty-six percent (n=236) were diagnosed with B-cell ALL; 42% (n=116) were treated on the LR arm, 41% (n=112) IR/HR arm, and 17% (n=46) VHR arm. Thirty-seven percent (n=102) of subjects were HMH-exposed, reporting housing (26%), food (22%), and/or utility (16%) insecurities. On unadjusted analysis the median (IQR) number of hospitalization days over the first 6-months of therapy was 37.5 (31-53) among HMH-exposed and 35 (27-45.5) among HMH-unexposed. After adjustment for sex and final risk group, the median difference in hospital days between HMH-exposed vs. unexposed groups in the overall cohort was 2.0 (95% CI: -0.8, 4.8; p=0.2), which also did not reach statistical significance. On unadjusted analysis, children treated on the most intensive VHR arm were hospitalized a median of 55.5 (IQR:51-64) days and experienced the greatest difference in inpatient days by poverty exposure; HMH-exposed 57 (53.5-68) days vs. unexposed 53 (48.5-63) days.

Discussion: In this study of trial-enrolled children with ALL, exposure to food, housing and/or utility insecurity was not associated with increased hospitalization during the first 6 months of chemotherapy. While not statistically significant, a clinically meaningful trend toward more inpatient days was observed amongst poverty-exposed children in the context of an underpowered sample size. Further investigation in larger cohorts is warranted, in particular among children receiving the most intensive therapy, given its potential relevance to children, families, and payors.