Why Do Patients With Blood Cancer Die Without Benefit of Hospice?

Kristin Jenkins

May 26, 2017

Why do so many patients with blood cancer die without benefit of hospice care?

Results from a survey of hematologic oncologists in the United States show that while most (68%) strongly agree that hospice care is helpful, almost half (46%) don't feel that home hospice care — as opposed to around-the-clock inpatient care — would meet their patients' needs.

Referrals could increase significantly, however, if hospice care provided red cell/platelet transfusions, adequately reimbursed payers/Medicare, and allowed oncologists to continue caring for their patients after hospice care started, according to Oreofe O. Odejide, MD, MPH, from the Department of Medical Oncology at Dana Farber Cancer Institute, Boston, Massachusetts, and colleagues.

The survey results were published online May 22 in Cancer.

Most clinicians who felt hospice care wasn't up to snuff were more likely than colleagues who considered it adequate to say they would refer patients if certain services were available, the study authors report. These services include red cell transfusions (67.3% vs 55.3%; P = .03), platelet transfusions (52.9% vs 39.7%; P = .02), and regular clinic visits (36.0% vs 19.0% P = .0005). Even clinicians who considered hospice care adequate said they would refer more patients if red cell transfusions were allowed, the researchers point out.

"These data suggest that although hematologic oncologists value hospice, concerns about the adequacy of services for blood cancer patients limit hospice referrals," Dr Odejide and colleagues comment. Rather than further educating hematologic oncologists on the value of hospice, they add, "interventions that tailor hospice services to their specific patient needs are more likely to be effective at increasing enrollment."

Timely hospice enrollment is now endorsed as an indicator of high-quality end-of-life care for patients with an estimated life expectancy of 6 months or less. Despite this, patients who die of hematologic cancers in the United States have the lowest rates of hospice use of all oncology patients. A previous study of patients with hematologic cancers demonstrated a 52% higher risk for a hospice stay of only 3 days or less compared with patients with solid malignancies, the study authors point out.

The finding that so many physicians thought hospice care was valuable — 52% even said they would enroll themselves if they had a diagnosis of terminal cancer — was surprising, the study authors admit, "given the low rates of timely hospice use among blood cancer patients." However, the current hospice model in oncology is predominantly outpatient or home-based and designed to control pain in patients with metastatic solid tumors, they note.

In an interview, Dr Odejide said lack of transfusion services may present a substantial barrier to hospice referrals but that the survey findings also indicate referral practices are potentially modifiable.

"Our findings suggest that developing innovative models of hospice delivery that include services that are well tailored to needs of blood cancer patients are likely to be effective in improving hospice use for this patient population," she said in an email. "Accordingly, we plan to conduct research that directly engages patients with blood cancers to characterize their needs near the end of life, with the goal of developing targeted interventions that tailor services to their specific needs."

Survey Details

For the study, an email survey was sent out between September 2014 and January 2015 to a total of 667 hematologic oncologists caring for adults with blood cancer. All had been randomly selected from the clinical directory of the American Society of Hematology. The median age of the respondents was 52 years, 76% were male, and 52% reported that "at least" 25% of their practice was composed of patients with solid tumors.

The survey consisted of 30 questions and used a 5-point Likert scale ranging from "strongly disagree" to "strongly agree" in response to statements such as "I feel home hospice is not adequate for the level of care some of my patients need" and "I would refer more patients to hospice if I were able to have clinic visits with them more often."

A total of 349 hematologic oncologists from 48 states completed the survey, for a response rate of 57%.

Because most hospices in the United States can't provide transfusions as a result of the fixed daily per-patient rates of most payers, including Medicare, policy changes are needed to make adequate hospice reimbursement available, Dr Odejiwe and colleagues say. They point out that the added costs would be offset by a reduction in the number of terminal hospitalizations and last-ditch treatment efforts.

The different disease trajectories of hematologic cancer — some patients require frequent long-term follow-up while others need high-intensity inpatient treatment — create "strong patient-provider bonds," they note. And, in fact, the hematologic oncologists surveyed said they didn't want their patients to feel abandoned after starting home hospice care. "This issue could be potentially addressed with innovative models that include so-called shared care or telemedicine," the researchers suggest.

Clinicians also play an important role in addressing other barriers to hospice care by making sure that conversations with patients happen while enrollment is still an option, Dr Odejiwe told Medscape Medical News. Sadly, this isn't always the case. "In previous work, we found that the majority of hematologic oncologists reported that end-of-life conversations typically occur 'too late,' and a substantial proportion reported that they typically conduct the first conversation regarding hospice when 'death is clearly imminent.'"

The study also illustrates the importance of research that directly engages physicians, Dr Odejiwe said. "Given that physicians play an important role in cancer care delivery, engaging them through research avenues such as surveys is essential in understanding and addressing barriers to optimal care for patients with cancer. We hope that findings from this study will encourage research that carefully characterizes the needs of patients with blood cancers so that systematic interventions that tailor hospice services to those unique needs can be developed."

This study was supported by funding from the National Palliative Care Research Center, Harvard Medical School, and the National Cancer Institute of the National Institutes of Health. The study authors have disclosed no relevant financial relationships.

Cancer. Published online May 22, 2017. Abstract

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