The Effect of Limited-English Proficiency on Hematopoietic Stem Cell Transplantation Outcomes: A Retrospective Cohort Study of Hispanic Pediatric Transplant Patients at a Single Institution.

Abstract

<h3>Background</h3> More than 25 million Americans have limited English proficiency (LEP) and are more likely than English-proficient (EP) patients to have poor health literacy, not understand their diagnosis, or experience complications from adverse drug effects. Hematopoietic stem cell transplantation (HSCT) is a potentially curative procedure for a variety of malignant and non-malignant diseases. However, HSCT requires prolonged hospitalization and excellent medication adherence to achieve good outcomes. Communication barriers between providers and LEP families of pediatric HSCT patients may further complicate this process and negatively affect clinical outcomes. <h3>Objectives</h3> The objectives of this study were to compare HSCT outcomes of Hispanic pediatric patients with LEP and EP families. Outcomes included overall survival, relapse, length of hospitalization, frequency of re-hospitalization and post-transplant complications including infections and graft-versus-host disease (GVHD). We hypothesized that LEP would be associated with worse outcomes. <h3>Methods</h3> We conducted a retrospective review of Hispanic or Latino pediatric patients receiving HSCT at Duke University from January 1, 2000 through March 15, 2019. Patients and families were identified as LEP or EP based on clinicians' notes, social work documentation or the signature of a Spanish interpreter on treatment consents. <h3>Results</h3> A total of 84 Hispanic/Latino patients were identified with 53 (63.1%) having LEP. There were no significant differences in age at transplant, sex, and race between these groups. Donor types, graft sources, and diagnoses were similar with the exception of more genetic diagnoses in the EP group (32%) than LEP (13%). The cumulative incidence of relapse, neutrophil engraftment, and acute GVHD were similar in both groups, as were the frequency of post-transplant infection and readmission. LEP patients were hospitalized on average 13 days longer than EP patients (Figure 1, p=0.06) and were more likely to have pre-transplant CMV reactivity (66%) than EP patients (30%, Figure 2, p=0.001). Overall survival was lower in LEP than EP but was not statistically significant (Figure 3). Multivariable Cox modeling suggested a potentially higher risk of death in LEP vs EP (hazard ratio=1.56, 95% CI: 0.38, 6.23). <h3>Conclusion</h3> Spanish-speaking patients with LEP undergoing HSCT may be at risk for prolonged hospitalization and are more likely to have pre-transplant CMV reactivity. These factors are known to be associated with post-transplant complications and death. Our results suggest LEP families are at higher risk for poor HSCT outcomes. Further study is warranted in a larger cohort.