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Need for transfusions delays hospice care for patients with leukemia
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ATLANTA — Although patients with leukemia dependent on transfusions appeared more likely to be referred to hospice care, median time on hospice was short, according to a population-based study presented at the ASH Annual Meeting and Exposition.
The short duration suggests transfusion dependence may delay referral to hospice care.
“The overall quality of end-of-life care for leukemia patients remains quite poor,” Thomas Leblanc, MD, MA, FAAHPM, assistant professor of medicine at Duke Cancer Institute, said during his presentation. “Yet, we’ve shown here that when leukemia patients utilize hospice care services, their performance on end-of-life quality measures is dramatically improved.”
Studies suggest patients with blood cancers use palliative and hospice services at end of life less frequently than those with solid tumors due to transfusion dependence and the inability of hospice organizations to provide life-extending transfusion support.
“It’s important to recognize this is not due to any kind of legal or reimbursement prohibition; it’s more of a practical matter whereby the per diem reimbursement from CMS for hospice care is relatively small and, practically, it does not allow for the provision of expensive therapies like chemotherapy, radiotherapy or things like transfusions support,” Leblanc said.
Researchers used the SEER-Medicare database to evaluate the association between transfusion dependence and outcomes at end of life among 21,076 Medicare beneficiaries (median age, 79 years; 56% men) diagnosed with acute (46% myeloid or lymphoblastic) and chronic (54% lymphocytic, myeloid or myelomonocytic) leukemias between 1996 and 2001. All patients died between 2001 and 2011 and more than 30 days after diagnosis.
Researchers defined transfusion dependence as receipt of two or more transfusions at least 5 days apart within 30 days before death or hospice enrollment. They measured cost of care at end of life as inflation-adjusted Medicare spending within 30 days before death.
Use of hospice services at end of life and duration of hospice stay served as study outcome measures.
Twenty percent of the study cohort was transfusion dependent before hospice enrollment or death. Transfusion-dependent patients appeared significantly younger, comprised mostly men and more often had acute leukemia.
The use of hospice at end of life — which increased from 35% in 2001 to 49% in 2011 (P < .0001) — occurred more frequently among patients with transfusion dependence (47%) than those without dependence (43%; P < .0001).
However, median time on hospice was 9 days overall, but was significantly shorter for transfusion-dependent patients (6 days vs. 11 days; P < .0001).
“We were surprised to find that hospice use increased overall, from 35% in 2001 to almost 50% in 2011,” Leblanc said. “However, more importantly, we found that median time on hospice was just 9 days, and this has not changed over time. There is concern that transfusion dependence may actually be a barrier to hospice referral.”
Hospice enrollees also had a lower likelihood of inpatient death (3% vs. 75%), chemotherapy use in the last 14 days of life (5% vs. 16%), and lower median Medicare spending at end of life ($7,662 vs. $17,783) than nonenrollees.
Transfusion dependence increased likelihood of hospice enrollment (RR = 1.07, 95% CI, 1.03-1.11), but was associated with a 51% shorter time on hospice (RR = 0.49, 95% CI, 0.44-0.54), and a 38% higher risk for receiving hospice services for less than 3 days (RR = 1.38, 95% CI, 1.26-1.52). The associations appeared similar for acute and chronic leukemias.
Researchers also observed an association between transfusion dependence and less frequent outpatient hospice referral in chronic (RR = 0.73, 95% CI, 0.65-0.82), but not in acute (RR = 0.96, 95% CI 0.90-1.03), leukemias.
“The big issue here is that practicing hematologists frequently say transfusions are a barrier to referring patients [to hospice care],” Leblanc said. “But, when you talk with hospice care organizations, they are concerned about the safety of providing transfusions in the home. There are also enormous logistical issues related to proximity to blood banks.”
Leblanc noted, however, that published studies conducted in Europe have shown transfusion support can be safely given in patients’ homes.
“Transfusions may help patients feel better or help prevent catastrophic bleeding, or help a patient live a little longer even though they are going to die of this disease,” Leblanc said. “But most folks aren’t interested when they are close to end of life, and that may be a main driver for why we tend to refer leukemia patients either late or not at all.” – by Chuck Gormley
Reference:
Olszewski AJ, et al. Abstract 277. Presented at: ASH Annual Meeting and Exposition; Dec. 9-12, 2017; Atlanta.
Disclosures: Leblanc reports a consultant role with Pfizer, honoraria from Celgene, Janssen and Helsinn Therapeutics, and research funding from AstraZeneca, Cambia Health Foundation and Seattle Genetics. No other authors report relevant financial disclosures.