Insurance and racial disparities in CAR T-cell therapy outcomes: A National Inpatient analysis.

11172 Background: To understand equity gaps for Chimeric antigen receptor T-cell (CAR-T) therapy, we conducted an analysis examining insurance-based and racial disparities in CAR-T cell therapy. Methods: Using the National Inpatient Sample (2020-2022), we identified CAR-T recipients via ICD-10-PCS procedure codes (XW0 series) with FDA-approved indications including diffuse large B-cell lymphoma (DLBCL), B-cell acute lymphoblastic leukemia (B-ALL), multiple myeloma, follicular lymphoma, and mantle cell lymphoma. The primary outcome was in-hospital mortality. Secondary outcomes included cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and ICU utilization. Multivariable logistic regression estimated adjusted odds ratios (aOR) controlling for age, sex, race, insurance status, and disease indication. Access disparities were assessed by comparing racial composition of CAR-T recipients to US Census population estimates. Results: Among 10,610 weighted CAR-T hospitalizations (mean age 59.4 years; 62.1% male; 97% at academic centers), the most common indications were DLBCL (46.9%), multiple myeloma (25.0%), and B-ALL (12.7%). Overall in-hospital mortality was 8.6%, CRS occurred in 42.3%, and ICANS in 19.7%. Compared to privately insured patients (mortality 5.5%), both Medicare (11.5%; aOR 1.59, 95% CI 1.32-1.92, p < 0.0001) and Medicaid patients (10.7%; aOR 1.89, 95% CI 1.45-2.47, p < 0.0001) experienced significantly higher mortality after adjustment for demographics, comorbidities, and indication. This disparity persisted across the study period, with the Medicare-to-Private mortality ratio increasing from 1.9x (2020) to 2.2x (2022). Black (9.1% of CAR-T recipients vs 13.6% US population) and Hispanic patients (13.7% vs 18.9%) were significantly underrepresented, receiving CAR-T at only 67% and 72% of expected rates based on population demographics, respectively. Black patients demonstrated significantly higher ICANS risk (aOR 1.38, 95% CI 1.16-1.64, p = 0.0003) but lower CRS risk (aOR 0.79, 95% CI 0.68-0.91, p = 0.001) compared to White patients. Black patients also experienced higher rates of ICU-level care (23.8% vs 16.6%) and mechanical ventilation (12.4% vs 8.1%). No significant sex-based disparities were observed in mortality (aOR 0.90, 95% CI 0.78-1.04, p = 0.17). Conclusions: We identified insurance-based mortality gaps with 60-90% higher adjusted mortality compared to privately insured patients. Concurrent access disparities result in Black and Hispanic patients being underrepresented by approximately one-third. Black patients who do receive CAR-T demonstrate distinct toxicity phenotypes with higher neurotoxicity and ICU utilization. These findings support the need to address barriers to CAR-T access and optimize outcomes across all patient populations.