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PAPER SPOTLIGHT
Examining Hospice Use Among Transfusion-
Dependent Patients With Leukemia
Since 2001, more patients with
leukemia are receiving hospice
services, which has been associ-
ated with improved quality of life,
according to an analysis published
in Blood. However, transfusion de-
pendence is a substantial barrier to
patients receiving these services,
as many hospice organizations
disallow life-extending transfusion
support. This translates to less
time in hospice care and poten-
tially higher risk of inpatient death
and higher Medicare spending,
lead author Thomas W. LeBlanc,
MD, and researchers reported.
“Leukemia clinicians have
long expressed frustrations about
hospice-care programs not provid-
ing transfusion support to their pa-
tients at end of life; however, there
wasn’t actually a study robustly
demonstrating any association
between transfusion dependence
and use of hospice-care services,”
Dr. LeBlanc, from Duke University
School of Medicine in Durham,
North Carolina, told ASH Clinical
News. “These findings, which dem-
onstrate an association between
transfusion dependence and use
of hospice-care services, highlight
a need for policy solutions allowing
for transfusion support among
patients with leukemia who are
enrolled in hospice.”
The researchers analyzed the
Surveillance, Epidemiology, and
End Results (SEER)-Medicare
database to identify 21,033 Medi-
care beneficiaries (median age
= 79 years; range = 73-84 years)
who were diagnosed with acute
and chronic leukemias and died
between 2001 and 2011.
All patients were 66 years or
older at the time of diagnosis and
had been continuously enrolled
in Medicare Parts A and B for at
least one year prior to diagnosis.
Patients who died within 30 days
of diagnosis were excluded from
the analyses.
Investigators then examined
the association between transfu-
sion dependence (defined as hav-
ing ≥2 transfusion events ≥5 days
apart within a 30-day period prior
ASHClinicalNews.org
to death or hospice admission)
and two primary endpoints: use of
hospice services at time of death
and duration of hospice length of
stay.
Secondary endpoints included:
who did not receive transfusions (6
vs. 11 days, respectively; p<0.001).
Multivariable analyses revealed
that, compared with patients
without transfusion dependence,
those with transfusion dependence
appeared to be more likely to:
• death in the inpatient setting
• receive hospice services for <3
• admission to an intensive
care unit (ICU) within 30 days
of death
days (RR = 1.37; 95% CI 1.25-
1.51; p value not reported)
• die in the inpatient setting
• receipt of chemotherapy
within 14 days of death
• hospice enrollment <3 days
prior to death
• outpatient referral to hospice
(defined as hospice admission
>2 days after discharge from
any preceding hospitalization)
• Medicare spending within a
30-day period prior to death
A total of 4,141 patients (20%)
were transfusion dependent be-
fore death or hospice enrollment.
Nearly half of the participants
(n=9,230; 44%) were receiving
hospice care at end of life. The
authors noted that this propor-
tion increased significantly during
the study period, from 35 to 49
percent (p<0.001).
Surprisingly, hospice enroll-
ment was higher among patients
who were transfusion dependent
than those who were not (48%
and 43%; relative risk [RR] = 1.08;
95% CI 1.04-1.12; p<0.001).
Among patients who received
end-of-life hospice care, the
researchers observed a significant
decrease in inpatient deaths and
chemotherapy use (p<0.001), but
no change in the proportion of
hospice stays lasting more than
three days (p<0.11).
The median duration of hospice
stay, regardless of transfusion-
dependent status, was nine days
(range = 3-28 days). However,
patients who were transfusion-
dependent had a 51-percent
shorter hospice stay than those
(RR=1.04; 95% CI 1.00-1.08;
p value not reported)
• be admitted to the ICU prior
to death (RR=1.05; 95% CI
1.00-1.10; p value not re-
ported)
However, transfusion-dependent
patients appeared to be less likely
to receive outpatient hospice re-
ferral (RR=0.89; 95% CI 0.84-0.94;
p value not reported).
The authors concluded that
transfusion dependence repre-
sents “a barrier to timely hospice
referral” but added that the
associations observed in their
study may not be causal. Review-
ing transfusion claims to the date
of death, rather than the date of
hospice enrollment, may have in-
troduced a “guarantee-time bias,”
which may explain the higher-
than-expected enrollment among
transfusion-dependent patients.
Also, because the analysis in-
cluded only Medicare beneficiaries
with leukemias, the findings may
not be generalizable to patients
enrolled in managed-care plans or
with other cancers or to younger
patients.
Future steps, Dr. LeBlanc said,
could include pilot-testing an
open-access program that would
allow patients with leukemia to
enroll in hospice care while also
receiving transfusion support for
palliative purposes.
“This will require some funding
and also partnership with payers,
such as the Centers for Medicare
and Medicaid Services,” he com-
mented, “but this change could
have a dramatic impact on the
well-being of patients and families
who are struggling with a terminal
leukemia diagnosis.”
“[Our data]
highlight
a need
for policy
solutions
allowing for
transfusion
support [in
hospice].”
—THOMAS W. LeBLANC, MD
Dr. LeBlanc added that
further research is necessary to
quantify the real-world advan-
tages and optimal delivery of
palliative transfusion support for
patients with leukemia at the
end of life. “Clinicians in both the
hematology and palliative-care
communities have raised ques-
tions about the appropriateness
of palliative transfusion support,
asking what it really accom-
plishes for patients and families,
and wondering whether it just
prolongs the dying process,”
he concluded. “While many of
us have seen what we think to
be substantial benefits from
palliative-intent transfusions in
our practices, there is a need for
larger, high-quality studies to
answer these important ques-
tions more definitively.”
The authors reported no con-
flicts of interest.
REFERENCE
LeBlanc TW, Egan PC, Olszewski AJ. Transfusion dependence,
use of hospice services, and quality of end-of-life care in
leukemia. Blood. 2018;132:717-26.
ASH Clinical News
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