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Racial minorities with hematologic cancers receive more aggressive end-of-life care
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Patients with hematologic malignancies received more aggressive care at the end of life than patients with solid tumors, according to results of a retrospective cohort study.
In addition, racial minorities with hematologic malignancies had lower rates of advance directive documentation and received significantly more aggressive care than white individuals with blood cancers.
“Slowly over the last couple years, there has been more of a recognition of trying to figure out if those disparities exist [for patients with hematologic cancers] and, subsequently, to figure out what to do about them,” Kedar Kirtane, MD, fellow in the hematology/oncology fellowship program at University of Washington and Fred Hutchinson Cancer Research Center, said in a press release.
Kirtane and colleagues assessed differences in hospitalization use patterns and documentation of advance care planning among 9,469 patients with solid tumors or hematologic malignancies. All patients underwent treatment at University of Washington Medicine and died between 2010 and 2015.
In a subgroup analysis that included those with hematologic malignancies, researchers assessed differences in outcomes associated with racial minority status.
Patients with hematologic malignancies appeared significantly more likely to receive aggressive hospital-based care, including hospitalization for 14 or more days and multiple hospital admissions during the last 30 days of life. Additionally, compared with those who had solid tumor malignancies, those with hematologic malignancies appeared more likely to receive ICU care and die in the hospital.
Results of the subgroup analysis showed racial minorities with hematologic malignancies were less likely than white individuals to have advance directive documentation, and they also were more likely to be hospitalized and receive ICU care within the last 30 days of life.
HemOnc Today spoke with Kirtane about the study results, how these findings fill a knowledge gap and the steps that can be taken to reduce these disparities.
Question: What prompted this research?
Answer: I have always been interested in palliative care and its relevance to hematologic malignancies. There has been a growing trend during the past couple years acknowledging that palliative care for hematologic malignancies is very important. I was specifically interested in advance directives in cancer populations. In the past, we were more comfortable with advance directives for patients with solid tumor malignancies, because it is sometimes a bit more difficult to do this in patients with leukemia or lymphomas. One reason for this is because it is really hard to identify how a patient with leukemia is going to fare. Although advance directives should ideally be talked about independent of clinical stage or prognosis, unpredictability in the disease trajectory has likely contributed to the differences in rates of advance care planning. Further, much of my research involves outcomes for racial minorities, so I wanted to characterize how racial minorities with hematologic malignancies were faring at the end of life.
Q: How did you conduct the research?
A: We conducted a retrospective cohort study using patient electronic health records. We looked at patients who died between 2010 and 2015. We looked for particular outcomes within the past 30 days of life. This included factors such as the number of ED visits, whether they received inpatient care within the last 30 days of life, whether that inpatient care lasted more than 2 weeks, and whether they died in the hospital. We additionally looked at whether there was documentation of advance directive within the EHR. We compared outcomes between those with solid tumors vs. those with hematologic malignancies. Among those with hematologic malignancies, we further compared non-Hispanic whites with racial minorities.
Q: What did you find?
A: As expected, we found that patients with hematologic malignancies tended to be in the hospital more within the last 30 days of life — receiving ICU care and inpatient care. They were also more likely to die in a hospital. Among our subset of patients with hematologic malignancies, racial minorities tended to spend more time receiving inpatient care and also spend more time in the ICU within the last 30 days of life. They additionally had less documentation of advanced directives than non-Hispanic whites.
Q: Did your study have limitations?
A: Because this is an administrative data set, it is not data that was obtained primarily for research purposes. It is possible that, within our system, we may have missed certain things. For example, the way that we looked at advanced directives was that an advanced directive had to be scanned into the EHR by the time of death to have constituted documentation. There are some flaws with this methodology and any data need to be interpreted with caution. Future research is needed to confirm our results.
Q: What are the potential clinical implications of the results , and what should be done to reduce these disparities?
A: The potential clinical implications of the results would depend on more prospective trials that use research data sets. It is possible that discussions about advanced care planning are occurring less frequently among racial minorities with hematologic malignancies, but it is also possible that some people simply do not want to have these discussions. Further, it is possible that when these discussions occur, some people are asking for more care. We simply need to do a better job at discussions of advance care planning with all of our patients, especially historically disadvantaged groups. In Seattle, we have a lot of immigrant populations that may not speak English, so we need to make sure the health care system is appropriately taking care of these patients and that they understand the implications of their disease. Additionally, we need to make sure we are talking about palliative care integration and advanced care planning as early as possible.
Q: Do you plan to conduct additional research on this topic?
A: The next step is to conduct a prospective trial to figure out how and why there are differences in advanced care planning among racial and ethnic minorities with hematologic malignancies. I hope to design such a trial to prospectively set up a way in which we can analyze if patients who are racial minorities are, in fact, getting less advanced care planning and — if so — develop a mechanism to understand why this is true. Subsequently, we would want to figure out how to fix that if it is not occurring on the same level as other patient populations. – by Jennifer Southall
Reference:
Kirtane K, et al. Abstract 859. Presented at: ASH Annual Meeting and Exposition; Dec. 9-12, 2017; Atlanta.
For more information:
Kedar Kirtane, MD, can be reached at Fred Hutchinson Cancer Research Center,
1100 Fairview Ave. North, Seattle, WA 98109; email:kkirtane@fredhutch.org.
Disclosure: Kirtane reports no relevant financial disclosures.