Quality of End-of-Life Care in Patients with Hematologic Malignancies: A Retrospective Cohort Study David Hui, Neha Didwaniya, Marieberta Vidal, Seong Hoon Shin, Gary Chisholm, Joyce Roquemore, Eduardo Bruera Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Background Advanced Hematologic Malignancies Patients with hematological malignancies often experience significant physical symptoms (Manitta et al. J Symp Manage 2011) Fatigue, insomnia, drowsiness, pain, dyspnea, and neuropathy Cytopenias, infections, and coagulopathies Symptom burden similar to patients with solid tumors (Fadul et al. J Palliat Med 2008) Patients with hematologic malignancies often receive intensive cancer treatments Stem cell transplant Chemotherapy use at the end-of-life (Hui et al. J Pain Symp Manage 2013; Hui et al. Cancer 201)
Background Quality of End-of-Life Care Last 30 days of life (Earle et al. J Clin Oncol 2004) Chemotherapy and targeted therapy use Rates of emergency room visits Hospitalization Intensive care unit (ICU) use Hospital death Palliative care referral The quality of end-of-life care has not been well examined in patients with hematologic malignancies
Objective To compare the quality of end-of-life care between patients with hematologic malignancies and solid tumors
Methods Design Study Design: retrospective cohort study Inclusion Criteria Age 18 or greater Reside within the Houston area Died of advanced cancer between 9/1/2009 and 2/28/2010 Had contact with our cancer center within the last 3 months of life Exclusion Criteria Transferred care to outside oncologists Relocated to another city Loss to follow up
Methods Data Collection Baseline demographics Quality of end-of-life care indicators related to the last 30 days of life: Chemotherapy and targeted therapy use* Any ER visit 2 ER visits* Any hospital admission 2 hospital admissions* >14 days of hospitalization* Hospital death* ICU admission* ICU death Palliative care referral * Composite aggressive end-of-life care score with 1 point per item (range 0-6). A higher score indicates more aggressive care
Methods Statistical Analyses Descriptive statistics for baseline characteristics Compared baseline characteristics and quality of end-of-life indicators between cohorts using t-test, Mann-Whitney test, Chi-square test, and Fisher exact test Multivariate logistic regression to determine factors associated with aggressive end-of-life care composite score (0 vs. 1-6) in the last 30 days of life
Results Study Flow Chart 1691 cancer patients who died between 09/01/2009 and 02/28/2010 816 (48%) advanced cancer patients were included for final analysis 300 (18%) had early stage disease 223 (13%) not followed by our institution at the end of life 143 (9%) were never seen here 96 (6%) last visit >3 months from death 63 (4%) had no cancer 29 (2%) had advanced cancer and had no evidence of disease 21 (1%) were pediatric 703 (86%) died of advanced solid tumors 113 (14%) died of advanced hematologic malignancies
Results Diagnosis of Hematologic Malignancies 113 (14%) patients had hematologic malignancies 34 (30%) patients with acute myelogenous leukemia 28 (25%) with multiple myeloma 27 (24%) with B cell non-hodgkin s lymphoma 7 (6%) with T cell non-hodgkin s lymphoma 7 (6%) with acute lymphocytic leukemia 5 (4%) with chronic lymphocytic leukemia 3 (3%) with chronic myleogenous leukemia 2 (2%) with Hodgkin s lymphoma
Results Patient Characteristics Patient Characteristics Solid tumors N=703 (%) Liquid tumors N=113 (%) P-value All patients N=816 (%) Age, mean (range) years 62 (22-97) 61 (21-88) 0.31 62 (21-97) Female sex 341 (49) 49 (43) 0.31 390 (48) White race 431 (61) 68 (60) 0.69 499 (61) Cancer type <0.001 Breast 71 (10) 0 (0) 71 (9) Gastrointestinal 178 (25) 0 (0) 178 (22) Genitourinary 89 (13) 0 (0) 89 (11) Gynecologic 61 (9) 0 (0) 61 (7) Head and neck 48 (7) 0 (0) 48 (6) Hematologic 0 (0) 113 (100) 113 (14) Other 94 (13) 0 (0) 94 (12) Respiratory 162 (23) 0 (0) 162 (20) Months between advanced 11.8 (4.5-23.8) 12.7 (4.4-39.8) 0.27 11.7 (4.5-25.2) cancer diagnosis and death, median (IQR)
Within the last 30 days of life Results Quality of End-of-Life Care Solid tumors N=703 (%) Hematologic malignancies N=113 (%) P-value Any ER visit 300 (43) 61 (54) 0.03 2 or more ER visits 83 (12) 17 (15) 0.35 Any hospital admission 333 (47) 91 (81) <0.001 2 or more hospital admissions 73 (10) 26 (23) <0.001 More than 14 days of hospitalization 54 (8) 43 (38) <0.001 Hospital death 110 (16) 53 (47) <0.001 ICU admission 55 (8) 44 (39) <0.001 ICU death 30 (4) 37 (33) <0.001 Chemotherapy use 98 (14) 49 (43) <0.001 Targeted therapy use 78 (11) 38 (34) <0.001 Chemotherapy/targeted agent use 160 (23) 60 (53) <0.001
Results Palliative Care Utilization Within the last 30 days of life Solid tumors N=703 (%) Hematologic malignancies N=113 (%) P-value Any palliative care consultation 329 (47) 37 (33) 0.006 Outpatient palliative care consultation 159 (48) 8 (22) 0.003 (among patient seen by palliative care) Palliative care unit admission 116 (17) 9 (8) 0.02 Months between advanced cancer 10.7 (3.9-22.1) 15.6 (4.4-43.4) 0.06 diagnosis and palliative care consultation Months between palliative care consultation and death 1.7 (0.6-4.6) 0.4 (0.1-1.2) <0.001
% Results Aggressiveness of EOL Care Score 100 80 60 40 20 0 Solid tumors Hematologic malignancies 0 1 2 3 4 5 6 Aggressiveness of Care Score Median score (IQR): solid tumors 0 (0-1) vs. hematologic 2 (1-3); P<0.001 Multivariate logistic regression: Hematologic (OR=6.63, 95% CI 4.11-10.72; P<0.001) Age (OR=0.97 per year, 95% CI 0.96-0.99; P<0.001)
Conclusion Patients with hematological malignancies were more likely to have multiple emergency room visits, intensive care unit admissions and death, and cancer treatments in the last weeks of life compared to patients with solid tumors. We also identified a relative lack of palliative care involvement in hematologic patients.
Limitations Generalizability single tertiary care cancer center Data collection end-of-life care outcomes limited to our own institution (i.e. may under-estimate level of aggressiveness)
Implications Our findings highlight the need to develop interventions to improve the quality of end-of-life care for patients with hematologic malignancies. Increase end-of-life discussions (Mack et al. J Clin Oncol 2012) Early outpatient palliative care referral (Hui et al. Cancer 2014) Clinical care pathways Clinical guidelines (e.g. NCCN) Reimbursement policy changes More research is needed!
Acknowledgements Palliative Care Dr. Eduardo Bruera Dr. Neha Didwaniya Dr. Marieberta Vidal Dr. Seong Hoon Shin Biostatistics Gary Chisholm Informatics Joyce Roquemore
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