Balancing Hospice Utilization With the Need for Transfusion in Leukemia

Is transfusion dependence a barrier to hospice utilization among older patients with leukemia who are enrolled in Medicare? This was the query posed by a collaborative study among researchers at Brown University, Rhode Island Hospital, and Duke Cancer Institute, presented during an Outcomes Research session at the 59th Annual Meeting and Exposition of the American Society of Hematology.¹

Patients with blood cancers use palliative and hospice services at end of life (EOL) less frequently than those with solid tumors. Previous studies have suggested that transfusion dependence (TD) may be a barrier to hospice enrollment, as life-extending transfusion support may not be allowed by hospice organizations. A 2015 study in Cancer², which evaluated healthcare utilization and EOL use in older patients with acute myeloid leukemia, found that hospice services were rarely utilized in their study cohort—the need for frequent blood product support in these patients may be a significant factor, the authors wrote.

A more recent study, which conducted a survey among US hematologic oncologists to gather their perspective on the utility of hospice care for patients with blood cancers, found that despite the value of hospice care, lack of adequate services prevented them from making hospice referrals. More than half of the survey respondents said that they were more likely to refer their patients to hospice services if red cell/platelet transfusions were available.³

Presenting the results of the current study was Thomas W. LeBlanc, MD, medical oncologist and palliative care physician with the Duke Cancer Institute.

“Most hospices do not allow transfusion support,” LeBlanc said, adding that while TD has been noted as a barrier for hospice use, it has not been well-studied in the context of leukemia. LeBlanc explained that the lack of transfusion support in hospices is a practical matter, where per diem reimbursement by CMS is small. “Therefore, we sought to evaluate the association between TD and outcomes at EOL among Medicare beneficiaries with acute and chronic leukemias.”

The study used claims information from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify Medicare beneficiaries 65 years and older with acute (myeloid or lymphoblastic) and chronic (lymphocytic, myeloid, or myelonomocytic) leukemias, diagnosed between 1996-2011 and who died in 2001-2011, at least 30 days from diagnosis. The longer timeframe, LeBlanc said, would account for the expected longer lifespan with chronic leukemias. TD was defined as at least 2 transfusions—at least 5 days apart, inpatient or outpatient—within 30 days before death or hospice enrollment.

Primary endpoints included use of hospice services at EOL and duration of hospice stay. Secondary endpoints included National Quality Forum performance measures for palliative care:

• Intensive Care Unit use within 30 days of death
• Chemotherapy in the last 14 days of life
• Hospice enrollment less than 3 days before death
• Hospice enrollment via outpatient referral

Cost of care at EOL was approximated as inflation-adjusted Medicare spending within 30 days before death.

Of the original 35,672 patients who were returned following a SEER-Medicare query, patients with incomplete Medicare claims as well as patients who enrolled in hospice prior to diagnosis were excluded. From the remaining pool of patients with complete Medicare data, patients with less than 30 days of survival were eliminated—this left the authors with a cohort of 21,076 eligible patients (median age 79 years, 44% women, 46% acute leukemias), 20% of whom were TD before death/hospice enrollment.

TD patients were significantly younger, more often male, and more often had acute leukemia. Use of hospice at EOL increased from 35% in 2001 to 49% in 2011 (P <.0001), and was higher among patients with TD than those without it (47% versus 43%, respectively; P <.0001). There was a reciprocal trend towards fewer inpatient deaths and chemotherapy use at EOL. Median time on hospice was 9 days, and it was significantly shorter for TD patients (6 versus 11 days, P <.0001), who were also more likely to receive hospice services for less than 3 days (27% versus 19%, P <.0001).

There was no significant difference in death in the inpatient setting between TD (46%) and non-TD (43%) patients. Chemotherapy use in the last 14 days of life was slightly higher in the TD patients (14% versus 11%).

LeBlanc said that TD was associated with a slightly higher likelihood of hospice enrollment (RR 1.07; 95% CI, 1.03-1.11), but also with a 52% shorter time on hospice (RR 0.48; 95% CI, 0.44-0.54). TD was also associated with less frequent outpatient hospice referral in chronic leukemia (RR 0.73; 95% CI, 0.65-0.82) but not in acute leukemia (RR 0.96; 95% CI, 0.90-1.03).

Importantly, hospice enrollees had a lower likelihood of inpatient death (3% versus 75%), chemotherapy use in the last 14 days of life (5% versus 16%), and lower median Medicare spending at EOL ($7662 versus $17,783) than non-enrollees.

LeBlanc concluded that that while hospice use has increased in patients with leukemias, the results of their study associate TD with significantly shorter hospice length of stay, which could implicate it as a barrier to hospice enrollment.

He warned however, that the use of claims-based data in their study prevented them from adjusting for any marker of disease severity. Additionally, the findings may not hold true for non-Medicare patient populations, including younger patients or those on managed-care plans.

References

1. Olszewski AJ, Egan PC, LeBlanc TW. Transfusion dependence and use of hospice among Medicare beneficiaries with leukemia. In: Proceedings from the 59th Annual Meeting and Exposition of the American Society of Hematology; December 9-12, 2017; Atlanta, GA. Abstract 277.

2. El-Jawahri AR, Abel GA, Steensma DP, et al. Health care utilization and end-of-life care for older patients with acute myeloid leukemia. Cancer. 2015;121(16):2840-2848. doi: 10.1002/cncr.29430.

3. Odejide OO, Cronin AM, Earle CC, Tulsky JA, Abel GA. Why are patients with blood cancers more likely to die without hospice? Cancer. 2017;123(17):3377-3384. doi: 10.1002/cncr.30735.