Health care utilization and end‐of‐life care for older patients with acute myeloid leukemia

Abstract

Background Health care utilization in older adults (≥60) with acute myeloid leukemia (AML) has not been well-studied. Methods We conducted a retrospective analysis of 330 consecutive older patients diagnosed with AML between 5/1/2005 and 12/23/2011 at two hospitals in Boston to examine their health care utilization and end of life (EOL) care. Using multivariable logistic and linear regression models adjusting for covariates, we also compared health care utilization for patients undergoing intensive induction (n=197; cytarabine/ anthracyline combination) versus non-intensive chemotherapy (n=133; single-agent therapy). Results The median number of hospitalizations for the entire cohort was 4.2 (range 1–18). Patients who died spent a mean of 28.3% of their life from diagnosis in the hospital and 13.8% of their life attending outpatient clinic appointments. Although the majority (87.9%) of patients died during the 2-year follow-up period, a minority (16.2% and 23.1%) utilized palliative care or hospice services, respectively. Within 30 days of death, 84.5% of patients were hospitalized, with 61.0% dying in the hospital. Among patients who died, those treated with intensive induction (versus non-intensive therapy) spent 30% more of their life in the hospital (p < 0.0001), and were less likely to utilize hospice services (OR 0.45, P = 0.05). Conclusions These findings highlight the intensity of health care utilization of older patients with AML, regardless of treatment modality. Despite the poor prognosis, palliative care and hospice services are rarely used. Future work should study novel health-care delivery models to optimize care throughout the course of illness and at the EOL.

Palliative Care in Patients with Hematological Malignancies

“…About 40% address the preferred site of death at this moment for the first time [14]. In addition, hematologists more likely favor prescribing systemic therapy with moderate toxicity and without survival benefit for patients with low performance status and an expected survival of a less than 1 month [15]. …”

“…For a large cohort of older patients, who had died from acute myeloid leukemia, El-Jawahri et al [15 ]described that they spend about 30% their life after diagnosis in the hospital and 15% attending outpatient clinic appointments. More than 80% were hospitalized in the last 30 days of their life and only a minority of them had received palliative care or hospice services.…”

When and why should patients with hematologic malignancies see a palliative care specialist?

“…32 In addition to the physical and psychological symptom burden, data suggest that many patients with hematologic malignancies may not be receiving high quality end-life care. 33,34 They are often hospitalized during the last month of life and frequently die in the hospital. Moreover, they more often die in the intensive care unit and/or receive chemotherapy during the last month of life.…”

“…Moreover, they more often die in the intensive care unit and/or receive chemotherapy during the last month of life. 33,34 Despite their significant needs, patients with hematologic malignancies rarely utilize palliative care services compared to patients with solid tumors. 7,34 Who needs palliative care?…”

“…For example, older patients with acute myeloid leukemia and multiple comorbidities are a highly vulnerable population with a poor prognosis, who may benefit greatly from early integration of palliative care to optimize symptom control and address end-oflife care needs. 34 The needs of these patients are very different than those with hematologic malignancies who are undergoing stem cell transplantation, who may also benefit from palliative care involvement primarily to manage complex physical and psychological symptoms even when the goal is to cure. 32 Last, we must also study and explore models for providing end-of-life care for patients with hematologic malignancies that can overcome typical limitations of hospice care in the US, which fails to recognize the palliative benefits of supportive transfusions and palliative chemotherapies, as these are often not provided as part of hospice care because of reimbursement limitations.…”