Shift from hospital to home would require ‘quantum change’ for care of hematologic malignancies

Home-based care is the most traditional form of health care.

For patients with cancer, providing care at home can improve quality of life, reduce costs and alleviate burdens on health care systems.

Home care can be particularly meaningful for patients at the end of life. However, needs of patients with hematologic malignancies — especially transfusion requirements — can delay initiation of hospice care.

“Unlike most solid malignancies, where advanced disease is incurable, many advanced hematologic cancers remain potentially curable. This lack of a clear distinction between the curative and end-of-life phase of disease for many blood cancers makes it challenging to identify the appropriate transition to end-of-life care,” Oreofe O. Odejide, MD, MPH, instructor in medicine at Harvard Medical School and member of the division of population sciences at Dana-Farber Cancer Institute, said in an interview. “Concerns about the adequacy of hospice services for the needs of patients with hematologic cancers may partly explain underuse of hospice in this population.”

However, researchers also are evaluating the use of a home-based model earlier in the course of a patient’s disease.

For instance, studies presented at the ASH Annual Meeting and Exposition in December and BMT Tandem Meetings in February showed hematopoietic stem cell transplantation at home is a feasible approach that can reduce hospital costs and resource use while improving rates of infectious complications.

HemOnc Today spoke with hematologists/oncologists about the benefits and challenges associated with home-based care, the underuse of hospice for patients with hematologic malignancies, the potential for HSCT at home, and the need for shifts in ideology and reimbursement practices to support home care models.

Home’s value

Providing care at home benefits patients and health care systems alike.

“Its value to the health system is reduced length of stay through patients being discharged earlier due to increased provider confidence to refer, because the care provided is from the same health system,” Karen Titchener, MS, APRN, director of the Hospital at Home program at Huntsman Cancer Institute and adjunct assistant professor at The University of Utah, said in an interview. “For the patients, the value is they receive the same high level of care they would get at the hospital but in their own home.”

The goal of Hospital at Home at Huntsman Cancer Institute — which will begin operation in July — is to provide at-home care for patients with cancer who have acute, palliative and hospice needs.

Titchener describes the Hospital at Home program as a “step up” from home health.

“Working jointly with the home health provider for the Hospital at Home program will provide and oversee all care given while trying to alleviate the burden of care from the family and patient by providing a more intensive level of input and taking more responsibility for the care,” she said.

Bruce Leff, MD, geriatrician at Johns Hopkins University School of Medicine, and colleagues conducted a pilot study of Hospital at Home in 1997 and showed the program was feasible and cost-effective for acutely ill adults aged 65 years and older who required hospital admission for pneumonia, chronic heart failure, chronic obstructive airways disease or cellulitis. Early data also suggested home-based programs resulted in fewer complications, greater patient and caregiver satisfaction, less caregiver stress, better functional outcomes and lower costs.

A meta-analysis by Caplan and colleagues showed home-based programs reduced risk for mortality (OR = 0.81; 95% CI, 0.69-0.95), readmission rates (OR = 0.75; 95% CI, 0.59-0.95) and cost (mean difference, –$1,567.11; 95% CI, –2,069.53 to –1,0649).

In an article published in Harvard Business Review, Leff described the Johns Hopkins model, which starts with determining a patient’s eligibility when they present in the ED and require hospital admission.

“The patient must meet validated clinical-appropriateness criteria for Hospital at Home and have housing where care can be provided safely,” Leff wrote. “However, having multiple chronic conditions and living alone are not obstacles to eligibility.”

Patients deemed eligible may receive initial rounds of treatment in the ED, then are transported home via ambulance where any needed services — oxygen, respiratory and IV therapies — are provided, and a nurse meets them to provide education. Thereafter, a nurse visits twice daily and the physician at least once daily — either in person or via telemedicine — and a care team is always available. Blood tests, X-rays, echocardiography, ultrasound, EKGs and other therapies can be provided at the home, while vitals are monitored remotely, Leff wrote, but patients who require other diagnostic tests that cannot be done at the home are transported to and from the hospital.

In addition to Huntsman Cancer Institute and Johns Hopkins, health care systems with Hospital at Home programs include Cedars Sinai Medical Center, Geisinger Health System, the VA, and Presbyterian Health Services in Albuquerque, New Mexico.

Such programs benefit family members and caregivers.

“If you have a family member dying in the hospital or having active treatment, and we know they don’t have curative disease, the burden of visiting is a big pressure on them,” Titchener said. “It is far less stress on both the family and the patient when they are in their own home environment.”

Although the health care delivery system is focused around hospitals, home care is increasingly being evaluated as a service for patients with a variety of conditions.

Source: .Duke University School of Medicine.

“There are a lot of things that can be done at the patient’s home that can be good for them in terms of improving outcomes and can be good for our health care system in terms of reducing costs and utilization,” Anthony D. Sung, MD, assistant professor of medicine at Duke University School of Medicine, said in an interview.

Still, the Hospital at Home program has been slow to gain traction in the United States primarily because Medicare does not pay for its services — unlike in other countries, such as Victoria, Australia, where a Hospital at Home admission is covered at the same rate as an inpatient hospital admission and represents upwards of 5% of hospital admissions.

Also, home hospice care is common for patients with solid tumors but can pose a challenge for patients with hematologic malignancies, who can rapidly deteriorate and are more susceptible to infections.

“We have to treat these patients very differently,” Titchener said.

Hospice challenges

Patients with hematologic malignancies have the lowest rates of hospice use among all oncology patients.

When these patients are referred to hospice, it often occurs within the last few days of life.

For instance, a study by Wang and colleagues published last year in Journal of Clinical Oncology showed use of hospice care among patients with acute myeloid leukemia increased from 31.3% in 1999 to 56.4% in 2012, but this was driven by late referrals. Nearly half (47.4%) of 5,847 patients who enrolled in hospice did so in the final 7 days of life; 28.8% enrolled in the final 3 days of life.

Transfusion requirements may drive this lack of or late hospice referral.

“A lot of these patients have a lengthy hospital stay and they won’t transition to hospice because transfusion gives them better quality of life, and transfusion often precludes hospice,” Gary J. Schiller, MD, hematologist at UCLA Medical Center, told HemOnc Today.

Patients who require transfusions may deteriorate rapidly without them.

“Some patients are good candidates for hospice; however, if they need blood transfusions to continue living because they have a condition affecting their blood counts, entering hospice and giving up transfusions would technically be shortening their lifespan,” Sung said.

At the ASH Annual Meeting and Exposition, Thomas Leblanc, MD, MA, FAAHPM, assistant professor of medicine at Duke Cancer Institute, and colleagues found that among Medicare beneficiaries with acute and chronic leukemias, 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 during his presentation. “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.”

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).

Transfusions may not be performed in the hospice setting due to reimbursement issues, lack of resources and other challenges.

Hospice is typically reimbursed by Medicare on a per diem basis per patient, regardless of the actual cost of care that a patient receives, Odejide said.

“Given this constraint, many hospice agencies are unable to provide transfusions,” she said. “Moreover, the current practice of administering transfusions in clinic or hospital settings, and not in the home, poses an additional barrier to transfusion access for patients enrolled in hospice.”

Patients with hematologic malignancies also may be susceptible to infections that require treatment unavailable in hospice care.

“Physicians can at times be hesitant to abandon the use of antimicrobials in this population [because] some hospices allow for some less expensive, oral antimicrobials while not allowing for more expensive, parenteral agents,” Michael R. Grunwald, MD, associate director of the leukemia division in the department of hematologic oncology and blood disorders at Levine Cancer Institute of Atrium Health, told HemOnc Today.

Improving end-of-life care

To overcome challenges associated with hospice for patients with hematologic malignancies, clinicians at UCLA generally prefer palliative care over hospice, Schiller said.

“[This] allows us to be in control, provide transfusion support or antibiotics without necessarily utilizing costly or strenuous interventions, such as hospitalization or ICU management,” he said.

Also, some institutions are offering patients on hospice transfusions at outpatient infusion centers in a reduced schedule.

“Patients and physicians may be hesitant to stop transfusions at the time when a patient is otherwise ready for hospice care,” Grunwald said. “Some hospices will occasionally allow for a limited, palliative transfusion schedule for specific patients. In certain settings, transfusions can be consistent with the goal of comfort.”

There is widespread effort to improve the use of palliative care for this population.

“Early referral to palliative care has been linked to improved survival in solid tumors. A push to boost palliative care referrals for patients with blood cancer may ultimately increase the appropriate use of hospice for these patients,” Grunwald said.

Despite these efforts, lack of hospice referrals may reflect a larger problem regarding the end-of-life care for patients with hematologic malignancies.

In a study published last year in Cancer, Odejide and colleagues found 68.1% of surveyed hematologic oncologists strongly agreed that hospice care is useful for their patients, but 46% said home hospice cannot adequately meet patients’ needs compared with inpatient hospice.

Researchers also found a lack of physician-patient communication may contribute to low hospice use.

“We found that the majority of hematologic oncologists reported that end-of-life conversations typically occur ‘too late,’ and a substantial proportion of hematologic oncologists reported that they typically conduct the first conversation regarding hospice when ‘death is clearly imminent,’” Odejide said.

The difficulty determining prognosis often complicates patients’ end-of-life care.

“Some patients with extensive disease at diagnosis may live for several years. As a result, there is heightened prognostic uncertainty for this population, which makes prognostication challenging,” Odejide said, adding that over 50% of hematologic oncologists in the national survey reported prognostic uncertainty as a barrier to high-quality end-of-life care.

Grunwald said many hematologic malignancies have the potential for cure and are responsive to treatments, adding to the difficulty.

“For this reason, it can be difficult for physicians to predict and/or acknowledge that a patient no longer has a meaningful chance of long-term survival,” he said.

HSCT at home

Home-based HSCT also is being explored as a model of care for patients with hematologic malignancies.

Patients undergoing autologous and allogeneic HSCT typically require lengthy inpatient hospitalizations, daily hospital visits or both. This increases risk for infections and hospital-induced delirium.

In a study presented at the ASH Annual Meeting and Exposition, Sung and colleagues evaluated whether home HSCTs were feasible and beneficial for patients and health care systems.

“There is growing awareness that prolonged hospitalizations are associated with nosocomial infections and high resource utilization and increased costs,” Sung said. “Also, by moving patients from a home environment to a hospital environment, you may affect things like their gut microbiome, which may influence stem cell transplant outcomes.”

Sung and colleagues evaluated 22 patients, including 16 who received autologous HSCT and six who received allogeneic HSCT.

Each morning, nurse practitioners or physician assistants made house calls to conduct assessments, examine patients and draw blood for laboratory studies. These studies were run at the hospital, and each afternoon a nurse returned to the patient’s home to provide home blood transfusions, IV fluids, electrolytes, antibiotics or other interventions. The medical team monitored transplant outcomes throughout the patient’s care.

Patients in the allogeneic HSCT group spent 72% of their days entirely at home, and patients in the autologous HSCT group spent 52% of their days at home. Febrile neutropenia represented the main reason for returning to the hospital (autologous, n = 9; allogeneic, n = 4). Aside from cytomegalovirus reactivation (allogeneic, n = 3), two patients in each group developed bloodstream infections.

Three patients in the allogeneic HSCT group who developed graft-versus-host-disease also spent the most time in the hospital prior to day 30 (median, 23 days vs. 11 days). One treatment-related death due to GVHD occurred.

Patients living at home may be more comfortable and have the courage to be more active and maintain a healthy diet.

However, there are also risks associated with home transplant, including the possibility of developing medical complications outside the hospital.

“It will take time to get a patient to the hospital because they have to call 911 and be transported. However, this is no different from patients receiving care in the outpatient setting, and we have not seen any situations where patients had a medical issue and were not able to receive care in time,” Sung said. “Bone marrow transplant is one of the most complicated procedures in modern medicine, so doing this in the patient’s home setting does represent a significant logistical challenge.”

These findings represent an advance in the field, Grunwald said; however, they also should be interpreted with some caution, because it is likely that only centers with appropriate resources and infrastructure can safely administer transplant care at home.

“Many patients on this study needed to return to the hospital or day hospital, most commonly for febrile neutropenia,” he said. “In addition, the generalizability of the results remains to be seen; at present, only a small number of centers would be equipped to provide home stem cell transplant care.”

Kodad and colleagues also presented data on the use of home autologous HSCT for patients with multiple myeloma at BMT Tandem Meetings.

Due to the high volume of patients, longer wait times and cost of health care, outpatient transplants for multiple myeloma have been standard of care at Vancouver General Hospital.

Researchers analyzed 752 patients who underwent autologous HSCT from January 2007 to June 2016.

The median time to transplant from diagnosis was 5 months (interquartile range [IQR], 4-6). Overall, 245 patients required hospital admission, of whom 74 were admitted within the first week of transplant. Median duration of admission was 6 days (IQR, 3-9).

Sixty-one percent of patients achieved 5-year OS. Researchers reported an all-cause mortality rate of 0.93% at 100 days and 4.78% at 1 year. At 100 days, four patients died of progressive disease — two related to pneumonia and one with cardiac complications.

The approach appeared feasible but requires a “multidisciplinary approach with close follow-up,” Kodad and colleagues wrote, because one-third of patients required hospital admission.

Mind shift

Due to the logistical challenges and reimbursement issues that would need to be sorted out, administrators within health care systems would need to fully embrace a home-based program in order for it to be effective and safe.

Patients and their caregivers involved with the home HSCT trial conducted by Sung and colleagues endorsed the program, noting their quality of life was well preserved.

“This strategy is safe and feasible,” Sung said. “The amount of support we received from patients and caregivers was very overwhelming and heartening.”

However, in general, perception of home-based programs has posed challenges.

“In medicine, they tell us not to let the data influence our knowledge,” Elihu Estey, MD, professor of medicine in the division of hematology at University of Washington School of Medicine, member of Fred Hutchinson Cancer Research Center and researcher at Seattle Cancer Care Alliance, told HemOnc Today at the time of the ASH presentation. “In other words, don’t confuse yourself with the facts. In my opinion, hospital administrators are simply scared to do it.

“I also think there’s fear on the part of the patients, because they believe they are receiving better care if they are in the hospital,” he added.

Experience and costs are additional concerns.

“In terms of safety and efficacy, this is completely feasible,” Estey said. “However, you need to have a facility experienced in home transplantation.”

Outpatient HSCT — which takes place at a facility that is open 7 days a week, with a doctor and nurse present to implement the same type of care as in an inpatient unit — has emerged as an intermediate option between home- and hospital-based transplant. Eligible patients must live within close proximity to the hospital in case of need for admission due to life-threatening issues and live with a care provider for observation.

“It is possible to provide care if you build these kinds of structures for an outpatient program, but you can’t do it for everybody,” Schiller said. “You can’t generalize this program to any leukemia patient receiving induction or consolidation therapy, because the outpatient program has to be able to mimic inpatient care.”

Patients at UCLA have had both positive and negative reactions to outpatient transplant, Schiller said.

“Some patients love it because, despite confinement to a residence close to the outpatient facility, they like that they aren’t in hospitals and exposed to the infections that exist, and they are not constrained by standard operating procedures of an inpatient unit,” he said. “Others just choose not to participate in an outpatient program because they do not have an outpatient provider or feel safe enough, or they want access to management at times when we wouldn’t have an outpatient facility open.”

Also, not every patient is eligible.

“We will never have more than 30%, to 50% at best, of our autologous stem cell transplant patients go through with this, because patients have mixed feelings and there are a lot of logistics,” Schiller said.

For instance, many insurance plans require patients to pay shared costs for outpatient services, which is not the case for most inpatient services.

However, there has been an effort to overcome these logistical challenges and make care outside of the hospital more accessible to a greater number of patients.

“The logistical challenge has been met, but it doesn’t mark a quantum change in the way we deliver this important therapy,” Schiller said. “It just makes it logistically more desirable and for some safer, but you have to do it in a careful way.” – by Melinda Stevens

Click here to read the , “Is telemedicine a viable option for the treatment of patients with hematologic malignancies?”

References:

Caplan GA, et al. Med J Aust. 2012;doi:10.5694/mja12.10480.

Kodad SG, et al. Abstract 27. Presented at: BMT Tandem Meetings; Feb. 21-25, 2018; Salt Lake City.

Leff B. “A vision for ‘hospital at home’ programs. Harvard Business Review. Available at: hbr.org/2015/12/a-vision-for-hospital-at-home-programs. Accessed on April 11, 2018.

Leff B, et al. J Am Geriatr Soc. 1999;47:697-702.

Odejide OO, et al. Cancer. 2017;doi:10.1002/cncr.30735.

Olszewski AJ, et al. Abstract 277. Presented at: ASH Annual Meeting and Exposition; Dec. 9-12, 2017; Atlanta.

Sung AD, et al. Abstract 745. Presented at: ASH Annual Meeting and Exposition; Dec. 9-12, 2017; Atlanta.

Wang R, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2017.72.7149.

For more information:

Michael R. Grunwald, MD, can be reached at michael.grunwald@carolinashealthcare.org.

Oreofe O. Odejide, MD, MPH, can be reached at oreofe_odejide@dfci.harvard.edu.

Gary J. Schiller, MD, can be reached at gschiller@mednet.ucla.edu.

Anthony D. Sung, MD, can be reached at anthony.sung@duke.edu.

Karen Titchener, MS, APRN, can be reached at karen.titchener@hci.utah.edu.

Disclosures: Grunwald, Odejide, Schiller, Sung and Titchener report no relevant financial disclosures.