Lack of Access to Transfusions Limits Hospice Use by Patients With Hematologic Malignancies

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Oreofe Odejide, MD, MPH

Oreofe Odejide, MD, MPH

A new survey finds that doctors would refer more patients with incurable blood cancers to hospice for end-of-life care if they could receive transfusions, which are generally not available because of hospice reimbursement policies. The findings, published by Oreofe Odejide, MD, MPH, and colleagues in Cancer,1 help explain why patients with leukemia, lymphoma, and other hematologic malignancies are less likely to receive hospice care at the end of life than are patients with solid tumors.

Researchers from Dana-Farber Cancer Institute found that a majority of hematologic oncologists strongly agreed that hospice care has value for patients with blood cancers; however, nearly half of the physicians in the survey felt home hospice is inadequate for their patients’ needs. Many patients with blood cancers need transfusions of red cells or platelets to control their symptoms, and most outpatient hospice settings don’t provide this service.

Dr. Odejide, a physician in -Dana-Farber’s Center for Lymphoma and a member of the Division of Population Sciences at Dana-Farber, said that Medicare typically provides a fixed cost per-diem reimbursement for hospice care that would not cover the cost of blood or platelet transfusions. In addition, much hospice care occurs in the patient’s home, where transfusions are impractical, said Dr. Odejide, although transfusions can be given in an outpatient clinic.

Previous research found that patients with blood cancers have the lowest rates of hospice use of all cancer patients and, compared with patients having solid tumors, are more likely to enroll in hospice late—within 3 days of death.

Key Findings

Dr. Odejide and her colleagues, including senior author Gregory A. Abel, MD, MPH, of Dana-Farber, surveyed hematologic oncologists in an effort to explain the disparity in hospice use.

Of the 349 physicians who responded, 68.1% strongly agreed that hospice care is “helpful” for patients with blood cancers. Doctors whose practices included greater numbers of patients with solid tumors in addition to blood cancer patients were more likely to strongly agree on the value of hospice. However, 46% of the respondents replied that home hospice is “inadequate” for their patients’ needs. More than half of the doctors surveyed said they would be more likely to refer to hospice if red cell and/or platelet transfusions were available. Also, 26.8% of the physicians agreed or strongly agreed that they would make more referrals to hospice if their patients could continue to have regular clinic visits after hospice begins.

Hematology and Hospice

  • 68.1% of physicians surveyed strongly agreed that hospice care is “helpful” for patients with blood cancers.
  • However, 46% of the respondents replied that home hospice is “inadequate” for their patients’ needs.

The takeaway finding, the authors said, is that “although hematologic oncologists value hospice, rates of referral are relatively low because the current hospice model may not meet the practical needs of blood cancer patients.” They added, “the fact that pain—a major focus of hospice—is less prevalent among patients with hematologic cancers compared to solid malignancies may further foster the viewpoint that hospice services are less relevant.”

Hospice referrals for blood cancer patients might increase if hospice services tailored to their specific needs were available, the authors suggested. Although providing transfusions would raise hospice costs, they concluded, “there would likely be concomitant cost savings through increased hospice enrollment leading to a reduction in terminal hospitalizations and/or intensive, nonefficacious treatments.” ■

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1. Odejide OO, Cronin AM, Earle CC, et al: Why are patients with blood cancers more likely to die without hospice? Cancer. May 22, 2017 (early release online).