Blood Transfusions in Leukemia a Deterrent to Hospice Care

Roxanne Nelson, RN, BSN

December 11, 2017

ATLANTA — Patients with late-stage blood cancers use hospice less frequently than patients with solid tumors, and once they do get to hospice, their stay is much shorter, as previously reported by Medscape Medical News

One barrier to hospice use in this population is the need for blood transfusion, according to new findings presented here at the American Society of Hematology (ASH) 2017 Annual Meeting.

Patients with leukemia who were transfusion dependent had a hospice stay that was about half as short as that in patients with leukemia who were not receiving blood transfusions. Those receiving transfusions had a 38% higher risk for receiving hospice care for less than 3 days.

"One of our main findings was that hospice use is increasing in leukemia patients, and has over time during the past 10 years," said study author Thomas Leblanc, MD, MA, assistant professor of medicine at Duke Cancer Institute, Durham, North Carolina.

"In 2011, the most recent year in the Medicare dataset that we used, almost half of the leukemia patients who died had used hospice care. So we were surprised at that," he said.

However, he said in an interview, another one of the main findings was that transfusion dependence is associated with much less meaningful use of hospice. "In other words, although more leukemia patients are using hospice, they're not doing it in a meaningful way," said Dr Leblanc. "The stay was very short — under 2 weeks — and you don't get very much benefit from those services when you only use them for hours or days. You really derive much more benefit when you use them for weeks or month, ideally."

The third main important finding was that patients with leukemia who do use hospice services do dramatically better on end-of-life quality measures. "There include things such as whether they die in a hospital, if they are admitted to the ICU [intensive care unit], and emergency room utilization," Dr Leblanc said. "This also translated to a cost reduction of about $10,000 per Medicare beneficiary for leukemia patients who utilized hospice care."

"So this is also a dramatic cost savings that is associated with better quality of care," he emphasized.

Barrier to Hospice Care

In this study, Dr LeBlanc and his colleagues examined the association between transfusion and the use of hospice services at end of life, using data from the linked Surveillance, Epidemiology, and End Results–Medicare database.

They identified 21,076 Medicare beneficiaries 65 years of age and older who had been diagnosed with various leukemias, either acute (myeloid or lymphoblastic) or chronic (lymphocytic, myeloid, or myelomonocytic). The patients were diagnosed  between 1996 and 2011 and died between 2001 and 2011. The primary endpoints were use of hospice services at end of life and the duration of hospice use.

Secondary endpoints were National Quality Forum performance measures for palliative and end-of-life care (ICU use within 30 days of death, chemotherapy in the last 14 days of life, hospice enrollment more than 3 days before death, and hospice enrollment via outpatient referral) and Medicare spending in the last 30 days of life.

Of this group, 20% were transfusion dependent before their death/hospice enrollment. Patients who were transfusion dependent tended to be significantly younger, were more often male, and more often had acute leukemia.

One interesting trend was that hospice use at the end of life increased from 35% in 2001 to 49% in 2011 (P for trend < .0001) and was actually slightly higher among patients who were transfusion dependent than among those who were not (47% vs 43%, respectively; P < .0001).

However, transfusion dependency was also associated with a 52% shorter time on hospice (relative duration, 0.48; 95% confidence interval, 0.44 - 0.54). While the median time on hospice was 9 days, it was significantly shorter for patients who were transfusion dependent (6 vs 11 days; P < .0001), and those who were transfusion dependent were also more likely to receive hospice care for less than 3 days (27% vs 19%; P < .0001).

When stratified by leukemia type, transfusion dependence was associated with less frequent outpatient hospice referral among patients with chronic leukemia, but not among those with acute leukemia.

The authors also found that when patients with leukemia used hospice care services, their performance on end-of-life quality measures was dramatically improved. Patients in hospice had a lower likelihood of inpatient death (3% vs 75%), receipt of chemotherapy during the last 14 days of life (5% vs 16%), a lower rate of admission to the ICU (47% vs 21%), and lower median Medicare spending at the end of life ($7662 vs $17,783) compared with those not in hospice.

This is a case of best care actually being less expensive for the system, Dr Leblanc explained. "So if we have a patient with late-stage terminal leukemia who is no longer going to benefit from any further active treatment, many of those patients would benefit from hospice. But many of them are not getting that care because they are still benefitting from transfusion support."

One of the take-home messages from this is that transfusion support really can be part of palliative care. "It can address their shortness of breath or fatigue, and it's really not fair that they have to choose between getting palliative transfusions that help them live and feel better or getting hospice care that we know is higher-quality care," said Dr Leblanc.

But there are some logistical problems when it comes to making blood transfusions a component of hospice care. Most hospice care is delivered in the home, and while there are home transfusion services, delivering blood is a more complex process.

Another important factor is reimbursement, Dr Leblanc noted.  "Under the current system, Medicare does not reimburse for blood transfusions," he said. "It is covered as part of the per-diem rate paid for hospice care."

Thus, under the current reimbursement protocol, the cost of blood transfusions is not compensated as a separate service. This presents a formidable cost barrier to a hospice's ability to provide patients with transfusions.

Innovative Solutions Needed

"The paper shows that leukemia patients are increasingly being enrolled in hospice but those who need blood transfusions are getting enrolled much later," said Cardinale B. Smith, MD, PhD, an associate professor of medicine and director of quality for cancer services, Mount Sinai Health System, New York City, who was approached for an independent comment. "They are thus likely not receiving quality care."

From a policy standpoint, in regard to the cost savings, it would be useful to look at new and innovative models to incorporate the use of transfusion. "That is something that we should really be strongly thinking about," she told Medscape Medical News.

This may be more difficult out in the community, but on the system level, institutions may be able to develop more innovative models and work with their local hospices, Dr Smith continued. "They may be able to come up with some kind of model for charging for transfusion."

Another important point to consider is whether transfusion is actually improving a patient's quality of life. "From a clinician's standpoint, there's always this reflex to offer a transfusion, because that's what is done when they are receiving active treatment, but we have to think critically if they are really improving quality of life," said Dr Smith.

Dr Leblanc made the following disclosures: Pfizer: consultancy; Celgene: honoraria; AstraZeneca: research funding; Boehringer Ingelheim: membership on an entity's board of directors or advisory committees; Seattle Genetics: research funding; Janssen: honoraria; Flatiron Health: consultancy; Cambia Health Foundation: research funding; Helsinn Therapeutics: consultancy, honoraria; Otsuka: membership on an entity's board of directors or advisory committees; American Cancer Society: research funding.

American Society of Hematology (ASH) 2017 Annual Meeting. Abstract 277, presented December 9, 2017.

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