Hematologic Malignancies Drive In-Hospital Death Rates

In the past 17 years, the overall rate of in-hospital deaths among patients with hematologic malignancies has decreased by 30 percent, with a corresponding rise in home and hospice-facility deaths, according to a report published in Blood Advances. This finding signals an improvement in the provision of end-of-life care for patients with hematologic malignancies, but the authors also found disparities in hospice use between patients with blood cancers and solid-tumor cancers and according to sociodemographic factors.

“Patients with hematologic cancers are more likely to die in the hospital, compared with patients with solid tumors,” lead author Fumiko Chino, MD, of the Duke University Medical Center in North Carolina, told ASH Clinical News. This risk can be attributed to many factors, she added, including disease trajectory, symptom burden, and patient or provider attitude toward palliative care/hospice services.

Place of death is a key indicator of quality of care, the authors explained: Research has shown associations between in-hospital death and unmet symptom needs for patients and prolonged grief disorder for caregivers, prompting efforts to improve access to palliative and hospice services earlier in the disease course. “Although there has been positive movement in the last two decades” in increasing the use of hospice services, Dr. Chino continued, “there remains a substantial gap [in the use of these services] for our patients at the end of life.”

To evaluate the changes in place of death for U.S. patients with hematologic malignancies, the authors obtained de-identified death certificate data from the National Center for Health Statistics between 1999 and 2015. They reviewed patients’ cancer subtype, place and year of death, and sociodemographic variables like age, sex, race, ethnicity, marital status, and level of education to test for disparities in place of death.

“Our research helps inform the ongoing conversation on how to improve end-of-life care for patients with cancer.”

–Fumiko Chino, MD

A total of 951,435 deaths from acute leukemia, chronic leukemia, aggressive lymphoma, nonaggressive lymphoma, and myeloma were recorded during the 17-year period.

Most individuals (73.9%) were older than 65 years at the time of death (median age = 72 years; interquartile range = 63-81 years).

Also, most patients were male (54.9%), white (88.0%), and non-Hispanic (93.9%). The most common hematologic malignancies in the population were:

  • acute leukemia (21.7%)
  • myeloma (20.0%)
  • chronic leukemia (10.5%)

Overall, the authors observed reductions in deaths in hospitals (from 54.6% in 1999 to 38.2% in 2017) and nursing facilities (from 13.1% to 11.9%). These were accompanied by increases in deaths at home (from 25.9% to 32.7%) and in hospice care (from 0% to 12.1%; p<0.001 for all).

Rates of in-hospital death varied widely based on location: The rate was highest in New York (61.6%) and lowest in Utah (32.5%). Utah also had the highest at-home death rate (50%) but the lowest hospice death rate (0.2%). Eleven states (Alabama, Alaska, Colorado, Hawaii, Idaho, Maryland, Massachusetts, North Dakota, Utah, Virginia, West Virginia) had aggregate hospice facility use of less than 2 percent, the authors reported.

There also were significant variations in rates of in-hospital death according to hematologic malignancy subtype and ethnicity. Individuals with a lower likelihood of dying at home or in a hospice facility, rather than in the hospital, had the following characteristics:

  • African American (odds ratio [OR] = 0.68; 95% CI 0.66-0.70; p<0.001)
  • Asian (OR=0.58; 95% CI 0.55-0.60; p<0.001)
  • Hispanic (OR=0.84; 95% CI 0.82-0.86; p<0.001)
  • diagnosis of chronic leukemia (OR=0.83; 95% CI 0.81-0.85; p<0.001)

Factors associated with a home or hospice facility death included:

  • older age (age 40-64 years: OR=1.34 [95% CI 1.28-1.39; p<0.001]; age ≥65 years: OR=1.89 [95% CI 1.81-1.97; p<0.001])
  • being married (OR=1.62; 95% CI 1.57-1.66; p<0.001)
  • having myeloma (OR=1.34; 95% CI 1.31-1.36; p<0.001)

When the researchers compared place-of-death statistics among patients with hematologic malignancies with patients with solid-tumor cancers, they observed that individuals with hematologic malignancies had a 65 percent higher likelihood of dying in the hospital (38.2% vs. 23.2%, respectively; p<0.001) and were 25 percent less likely to die at home (32.7% vs 43.6%; p<0.001).

“Our research helps inform the ongoing conversation on how to improve end-of-life care for patients with cancer,” Dr. Chino explained. “By looking at comprehensive national data that includes almost 1 million patients with hematologic cancers, we are able to highlight the disparities that exist in place of death and bring attention to the populations that are potentially at greatest risk for aggressive and/or futile care. These patients may receive the most benefit from early referral to palliative care.”

The potential inaccuracies of death certificates, as well as the lack of data on the intensity of end-of-life care that patients received, are possible limitations associated with the retrospective analysis.

“An open, trusting relationship between oncologists and their patients is essential to quality cancer care,” Dr. Chino said when asked about how this study’s findings could shape end-of-life discussions. “Having honest conversations about prognosis, expectations, and potential complications of treatment is vital to shared decision making. Transitions between treatment regimens are excellent opportunities to re-discuss goals of care and patient hopes and fears for the future.”

The authors report no relevant conflicts of interest.

Reference

Chino F, Kamal AH, Chino J, LeBlanc TW. Disparities in place of death for patients with hematological malignancies, 1999 to 2015. Blood Adv. 2019;3:333-8.

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