Economic Disparities Among Pediatric Acute Lymphoblastic Leukemia Readmissions in the United States: A Decade Trend Study

BACKGROUND Advances in the treatment of childhood acute lymphoblastic leukemia (ALL) have led to significant improvements in survival. However, the risks of treatment-related morbidity and mortality remain high, often resulting in unplanned readmissions. While it is well-documented that socio-economic status influences hospital readmissions, there is limited data on its influence on readmissions trends specifically within the pediatric ALL population. This study examined the impact of household income on variations in readmission trends over the past decade among pediatric patients with ALL in the United States. METHODS This was a retrospective interrupted trends study involving pediatric hospitalizations for ALL in the US, utilizing the Nationwide Readmissions Database (NRD) for 2010, 2012, 2014, 2016, and 2018. Using unique hospitalization identifiers, primary hospitalizations for ALL were identified as index hospitalizations. A subsequent hospitalization involving the same patient within 30 days was tagged as readmission. We excluded hospitalizations of patients above 18 years, as well as elective and traumatic admissions and readmissions. The median household income (MHOI) quartiles variable stratifies patients into four categories: 1-low income, 2-middle income, 3-upper middle income, or 4-high income.The study examined the biodemographic trends in pediatric ALL hospitalizations within the study period. We compared trends in 30-day all-cause readmission (30ACR) across the four income quartiles. We employed multivariate logistic trend analysis to calculate odds of trends in 30ACR, adjusted for age and sex. All p values were two-sided, with 0.05 set as the threshold for statistical significance. RESULTS The study included 5,236 hospitalizations. Over the study period, the mean age of children readmitted following ALL was 7.7 years (SD: 4.6), with no significant variation by MHOI. The majority of the patients were males (56.8%) with no significant variation in gender distribution by MHOI. Additionally, there was no significant variation in age distribution and comorbidity burden across the different MHOI quartiles. The 30ACR varied for the study with a trend towards increasing odds of 30-day readmission (p-trend <0.001). This was higher in teenagers compared to children under five years old. However, there was no significant difference by MHOI. There was a trend towards increased odds of inpatient mortality following readmission, adjusted for age, sex, and MHOI (p-trend =0.035). CONCLUSION To the best of our knowledge, this is the first study to report the relationship between household income status and readmission trends in childhood ALL. Our findings indicate a significantly increasing trend in 30-day readmissions for ALL with associated higher inpatient mortality odds. Notably, this trend was similar among the socioeconomic groups. Although, it is important to recognize that not all readmissions reflect poor hospital or post-discharge care due to the complexity of this patient population, these findings emphasize the urgent need for continuous, comprehensive interventions to effectively alter the post-discharge course and improve outcomes for these vulnerable patients.