CLINICAL NEWS
in a Different Vein
Research from ASH’s online peer-reviewed
journal, Blood Advances
Hematologic Malignancies Drive In-Hospital
Death Rates
In the past 17 years, the overall rate
of in-hospital deaths among patients
with hematologic malignancies has
decreased by 30%, with a correspond-
ing rise in home and hospice-facility
deaths, according to a report published
in Blood Advances. This finding signals
an improvement in the provision of
end-of-life care for patients with hema-
tologic malignancies, but the authors
also found disparities in hospice use
between patients with blood cancers
and solid-tumor cancers and according
to sociodemographic factors.
“Patients with hematologic cancers are
more likely to die in the hospital, com-
pared with patients with solid tumors,”
lead author Fumiko Chino, MD, of the
Duke University Medical Center in North
Carolina, told ASH Clinical News. This
risk can be attributed to many factors,
she added, including disease trajectory,
symptom burden, and patient or provider
attitude toward palliative care/hospice
services.
“Our research
helps inform
the ongoing
conversation on
how to improve
end-of-life care
for patients with
cancer.”
–FUMIKO CHINO, MD
Place of death is a key indicator of qual-
ity of care, the authors explained: Research
has shown associations between in-hospital
death and unmet symptom needs for
patients and prolonged grief disorder for
caregivers, prompting efforts to improve
access to palliative and hospice services
earlier in the disease course. “Although
there has been positive movement in the
last two decades” in increasing the use of
hospice services, Dr. Chino continued,
there are substantial gaps in the uptake of
these services for patients at the end of life.
32
ASH Clinical News
To evaluate the changes in place of
death for U.S. patients with hemato-
logic malignancies, the authors obtained
de-identified death certificate data from
the National Center for Health Statistics
between 1999 and 2015. They reviewed
patients’ cancer subtype, place and year
of death, and sociodemographic vari-
ables like age, sex, race, ethnicity, marital
status, and level of education to test for
disparities in place of death.
A total of 951,435 deaths from acute
leukemia, chronic leukemia, aggressive
lymphoma, nonaggressive lymphoma,
and myeloma were recorded during the
17-year period.
Most people (73.9%) were older than
65 years at the time of death (median age =
72 years; interquartile range = 63-81 years).
Also, most patients were male (54.9%),
white (88.0%), and non-Hispanic (93.9%).
The most common hematologic malig-
nancies in the population were:
• acute leukemia (21.7%)
• myeloma (20.0%)
• chronic leukemia (10.5%)
Overall, the authors observed reductions
in deaths in hospitals (from 54.6% in 1999
to 38.2% in 2017) and nursing facilities
(from 13.1% to 11.9%). These were ac-
companied by increases in deaths at home
(from 25.9% to 32.7%) and in hospice care
(from 0% to 12.1%; p<0.001 for all).
Rates of in-hospital death varied
widely based on location: The rate was
highest in New York (61.6%) and lowest
in Utah (32.5%). Utah also had the highest
at-home death rate (50%) but the lowest
hospice death rate (0.2%). Eleven states
(Alabama, Alaska, Colorado, Hawaii,
Idaho, Maryland, Massachusetts, North
Dakota, Utah, Virginia, West Virginia)
had aggregate hospice facility use of less
than 2%, the authors reported.
There also were significant variations
in rates of in-hospital death according
to hematologic malignancy subtype and
ethnicity. Individuals with a lower likeli-
hood of dying at home or in a hospice
facility, rather than in the hospital, had
the following characteristics:
• African American (odds ratio [OR] =
0.68; 95% CI 0.66-0.70; p<0.001)
• Asian (OR=0.58; 95% CI 0.55-0.60;
p<0.001)
• Hispanic (OR=0.84; 95% CI 0.82-
0.86; p<0.001)
• diagnosis of chronic leukemia
(OR=0.83; 95% CI 0.81-0.85;
p<0.001)
Factors associated with a home or hos-
pice facility death included:
• older age (age 40-64 years: OR=1.34
[95% CI 1.28-1.39; p<0.001]; age ≥65
years: OR=1.89 [95% CI 1.81-1.97;
p<0.001])
• being married (OR=1.62; 95% CI
1.57-1.66; p<0.001)
• having myeloma (OR=1.34; 95% CI
1.31-1.36; p<0.001)
When the researchers compared place-
of-death statistics among patients with
hematologic malignancies with patients
with solid-tumor cancers, they observed
that individuals with hematologic
malignancies had a 65% higher likeli-
hood of dying in the hospital (38.2% vs.
23.2%, respectively; p<0.001) and were
25% less likely to die at home (32.7% vs
43.6%; p<0.001).
“Our research helps inform the
ongoing conversation on how to
improve end-of-life care for patients
with cancer,” Dr. Chino explained. “By
looking at comprehensive national data
that includes almost 1 million patients
with hematologic cancers, we are able
to highlight the disparities that exist in
place of death and bring attention to the
populations that are potentially at great-
est risk for aggressive and/or futile care.
These patients may receive the most
benefit from early referral to palliative
care.”
The potential inaccuracies of death
certificates, as well as the lack of data
on the intensity of end-of-life care that
patients received, are possible limita-
tions associated with the retrospective
analysis.
“An open, trusting relationship
between oncologists and their patients
is essential to quality cancer care,” Dr.
Chino said when asked about how this
study’s findings could shape end-of-life
discussions. “Having honest conversa-
tions about prognosis, expectations, and
potential complications of treatment is
vital to shared decision making. Transi-
tions between treatment regimens are
excellent opportunities to re-discuss
goals of care and patient hopes and fears
for the future.”
The authors report no relevant con-
flicts of interest. ●
REFERENCE
Chino F, Kamal AH, Chino J, LeBlanc TW. Disparities in place of
death for patients with hematological malignancies, 1999 to 2015.
Blood Adv. 2019;3:333-8.
June 2019