Lack of access to transfusions limits hospice use by blood cancer patients

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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 help explain why patients with leukemia, lymphoma, and other hematologic malignancies – blood cancers – are less likely to receive hospice care at the end of life than are patients with solid tumors.

Reporting in the journal Cancer, researchers from Dana-Farber Cancer Institute found that a majority of hematologic oncologists strongly agreed that hospice care has value for blood cancer patients; 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.

Oreofe Odejide, MD, MPH, first author of the study and a physician in Dana-Farber’s Center for Lymphoma as well as 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 Odejide, although transfusions can be given in an outpatient clinic.

Timely use of hospice, which focuses on patient comfort and quality of life, is considered an indicator of high-quality end-of-life care. Patients who use hospice have a lower incidence of admissions to hospitals and intensive care units and a lower incidence of invasive procedures during the last year of life. 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 three days of death.

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 percent 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 percent 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 percent 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.

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.” In addition, the researchers said, “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.”

Based on their findings, the authors suggest that referrals to hospice for blood cancer patients might increase if additional hospice services tailored to their specific needs (e.g. transfusions) were available – and that would require changes in hospice reimbursement policies. 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, non-efficacious treatments.”

Abel is also in the Division of Population Sciences as well as the Center for Leukemia at Dana-Farber.

Support for the research included grants from the National Palliative Care Research Center and the National Cancer Institute R25CA092203.

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