Because many hospice organizations disallow life-extending transfusion support, transfusion dependence (TD) can pose a substantial barrier to enrolling patients with leukemia in palliative or end-of-life (EOL) services, according to a report presented at the 2017 ASH Annual Meeting. When these patients are enrolled, they spend about half as much time receiving hospice care as patients who do not require transfusions.
Adam J. Olszewski, MD, from the Alpert Medical School of Brown University in Providence, Rhode Island, and colleagues evaluated the association between TD (defined as requiring ≥2 transfusions in the 30 days before death or hospice enrollment) and EOL outcomes among Medicare beneficiaries diagnosed with acute and chronic leukemias between 1996 and 2011 and who died between 2001 and 2011 (after at least 30 days from diagnosis).
Among the 21,076 eligible patients (median age = 79 years; range not provided) identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, 20 percent were transfusion dependent before death or hospice enrollment. Patients in this group were significantly younger, more often men, and more often had acute leukemia, the researchers noted.
Between 2001 and 2011, use of hospice at EOL increased in the entire leukemia population, from 35 percent to 49 percent (p for trend < 0.0001). Compared with those not enrolled in hospice, enrollees had a lower likelihood of inpatient death (3% vs. 75%; p value not provided), chemotherapy use in the last 14 days of life (5% vs. 16%; p value not provided), and lower median Medicare spending at EOL ($7,662 vs. $17,783; p value not provided).
Surprisingly, enrollment was higher among patients with TD than without (47% vs. 43% p<0.0001); after adjusting for age, sex, time from diagnosis, and other baseline characteristics, patients with TD were 7 percent more likely to receive hospice (relative risk [RR] = 1.07; 95% CI 1.03-1.11).
However, that slight increase did not translate into “meaningful use” of hospice care, the authors reported. For example, the median time on hospice was nine days (range not provided) for the entire patient population, but patients with TD spent significantly less time on hospice than patients without TD (6 vs. 11 days; RR=0.49; 95% CI 0.44-0.54; p<0.0001). Transfusion-dependent patients were 38 percent more likely to receive hospice services for less than three days (27% vs. 19%; RR=1.8; 95% CI 1.26-1.52; p<0.0001). These relationships remained similar in patients with acute and chronic leukemias (p>0.05).
This finding contrasts with data about enrollment among patients with myelodysplastic syndromes and TD, “suggesting that TD may correlate with severity of illness,” Dr. Oslzewski reported.
The findings “indicate that the need for transfusion support may significantly delay hospice enrollment,” the authors concluded. “Because use of hospice services is associated with lower use of resources and costs at EOL, allowing palliative transfusions for patients with terminal leukemia may maximize the benefits of hospice from both patients’ and society’s perspective.”
These results support the notion of Medicare adding reimbursement for transfusion in hospice, which would mean fewer patients would have to choose between receiving palliative care and receiving transfusions, Dr. Oslzewski explained. “While hospice use in leukemias appears to be increasing, a large proportion of patients still die in the hospital,” he added. “Hospice care increases the likelihood of dying at home, where most Americans say they prefer to be at the EOL.”
Study limitations include variance in the data collected in the SEER database. The authors also did not collect information on cause of death.
The authors report financial relationships with Celgene, AstraZeneca, and Boehringer Ingelheim. The study was supported by a research grant from the American Cancer Society.
Olszewski AJ, Egan PC, LeBlanc TW. Transfusion dependence and use of hospice among Medicare beneficiaries with leukemia. Abstract #277. Presented at the 2017 ASH Annual Meeting, December 9, 2017; Atlanta, GA.