Transfusion Dependence May Hinder Quality End-of-Life Care in Medicare Beneficiaries With Leukemia

In older patients with leukemia, transfusion dependence (TD) is a common phenomenon that appears to impede quality end-of-life care related to hospice enrollment. Results of a new study show that although Medicare beneficiaries with TD are more likely to use hospice services than those without TD, the duration of their hospice care is substantially shorter due to delayed referral.

Thomas W. LeBlanc, MD, MA, MHS, of the Duke Cancer Institute, presented results from an observational study of patterns in hospice enrollment among older patients with leukemia at the American Society of Hematology’s 59th Annual Meeting & Exposition, December 9 to 12, 2017, in Atlanta, GA.

“We found a significant association between TD and less meaningful use of hospice care at the end of life among patients with leukemia,” LeBlanc said.

The study included 21,076 patients aged 65 years or older from the SEER-Medicare database who were diagnosed with acute or chronic leukemia between 1996 and 2011. All patients died between 2001 and 2011, after surviving at least 30 days from the time of their leukemia diagnosis. Patients were considered to have TD if they required 2 or more transfusions, at least 5 days apart, within 30 days of death or hospice enrollment

Increased use of hospice care
Between 2001 and 2011, the proportion of patients with leukemia who entered hospice increased from 35% to 49% (P < .001). Although hospice use increased, the time in hospice care was often short. The median time in hospice for all patients with leukemia was 9 days and remained stable throughout the study.

According to several National Quality Forum performance measures, hospice enrollment is associated with improved care quality at the end of life (Table). Compared with those who did not enroll in hospice, patients who enrolled in hospice were far less likely to die in the hospital (75% vs 3%), less likely to be admitted to the intensive care unit during the last month of life (47% vs 21%), and less likely to undergo chemotherapy during the last 2 weeks of life (16% vs 5%). Hospice enrollment was also associated with lower median Medicare spending for end-of-life care ($7,662) compared with nonenrollment ($17,783).

TABLE. Quality of End-of-Life Care by Hospice Enrollment in Patients With Leukemia

NQF Quality Measure Enrolled in Hospice Not Enrolled in Hospice
Died in the hospital 3% 75%
Admitted to the ICU in the last 30 days of life 21% 47%
Received chemotherapy in the last 2 weeks of life 5% 16%

ICU = intensive care unit; NQF = National Quality Forum.

TD and delayed hospice referral
In total, 1 in 5 patients (20%) met the criteria for TD. Patients with TD tended to be younger (77 years vs 79 years), were more likely to be male (59% vs 56%), and were more likely to have acute leukemia (72% vs 39%) than those without TD.

Patients with TD were 7% more likely than those without TD to enroll in hospice (RR, 1.07; 95% CI, 1.03-1.11). According to LeBlanc, a slightly higher enrollment in hospice is expected among patients with TD, given the greater severity of their leukemia.

Once patients were enrolled in hospice, however, TD was associated with a 52% shorter hospice duration (RR, 0.48; 95% CI, 0.44-0.54). The median stay in hospice for patients with TD was 6 days, compared with 11 days for patients without TD (P < .001). “These findings suggest that the need for transfusion support significantly delays timely hospice referral for patients with TD,” LeBlanc said.

Patients with chronic leukemia are especially susceptible to referral disparities. Whereas TD had no effect on the rate of referral to outpatient hospice for patients with acute leukemia (RR, 0.96; 95% CI, 0.90-1.03), TD decreased the likelihood of referral by 27% among patients with chronic leukemia (RR, 0.73; 95% CI, 0.65-0.82).

“System-based barriers contribute to delays in hospice enrollment for patients with TD,” LeBlanc said. Hospice organizations typically do not allow transfusion support that is considered a form of life-extending treatment rather than strictly palliative care. Medicare reimbursement policies further disincentivize hospice organizations from providing transfusion support.

In summary, the overall quality of end-of-life care for Medicare beneficiaries with leukemia is poor in current practice and made worse by a delay in hospice enrollment for patients with TD, LeBlanc said. He cautioned that these findings may not translate to non-Medicare patient populations, including patients with leukemia who are younger and/or covered by commercial insurance.

“Policy solutions allowing for reimbursement of palliative-intent transfusions under the hospice benefit may help maximize the benefits of hospice care for people with leukemia, improve quality of end-of-life care, and reduce overall costs,” LeBlanc concluded.

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