End-of-life care quality outcomes among Medicare beneficiaries with hematologic malignancies

Abstract

Patients with hematologic malignancies are thought to receive more aggressive end-of-life (EOL) care and have suboptimal hospice use compared with patients with solid tumors, but descriptions of EOL outcomes from comprehensive cohorts have been lacking. We used the population-based Surveillance, Epidemiology, and End Results-Medicare dataset to describe hospice use and indicators of aggressive EOL care among Medicare beneficiaries who died of hematologic malignancies in 2008-2015. Overall, 56.5% of decedents used hospice services for median 9 days (interquartile range, 3-27), 33.0% died in an acute hospital setting, 36.8% had an intensive care unit (ICU) admission in the last 30 days of life, and 13.3% received chemotherapy within the last 14 days of life. Hospice use was associated with 96% lower probability of inpatient death (adjusted risk ratio [aRR], 0.038; 95% confidence interval [CI], 0.035-0.042), 44% lower probability of an ICU stay in the last 30 days of life (aRR, 0.56; 95% CI, 0.54-0.57), and 62% decrease in chemotherapy use in the last 14 days of life (aRR, 0.38; 95% CI, 0.35-0.41). Hospice enrollees spent on average 41% fewer days as inpatient during the last month of life (adjusted means ratio, 0.59; 95% CI, 0.57-0.60) and had 38% lower mean Medicare spending in the last month of life (adjusted means ratio, 0.62; 95% CI, 0.61-0.64). These associations were consistent across histologic subgroups. In conclusion, EOL care quality outcomes and hospice enrollment were suboptimal among older decedents with hematologic cancers, but hospice use was associated with a consistent decrease in aggressive care at EOL.

Graphical abstract

Figure 1.

Characteristics of Medicare beneficiary decedents with hematologic malignancies included in the study. (A) Cohort selection for analysis; the main analysis was conducted in the population of beneficiaries whose death was ascribed to their hematologic malignancy on the death certificate, but a sensitivity analysis confirmed findings in the entire population, regardless of reported cause of death. (B) Diagram showing claims-based covariates (indicators of palliative care needs ascertained within 30 days before hospice enrollment for hospice enrollees or before death for nonenrollees) and EOL outcomes (indicators of aggressive EOL care), including 3 NQF EOL care quality indicators. (C) Trends in the proportions of decedents with hematologic malignancies using hospice, dying in the acute care hospital, having an ICU admission, or receiving chemotherapy at EOL. (D) Linearized trends in median hospice LOS and in median number of days spent in the inpatient setting (within the last 30 days of life). P values for trends were derived from univariate robust Poisson models. MDS, myelodysplastic syndrome; MPN, myeloproliferative neoplasm.

Figure 2.

EOL care quality outcomes among Medicare beneficiaries with hematologic malignancies across major histology groups, stratified by hospice use. Proportion of patients dying in the acute care hospital (A), having an ICU admission in the last 30 days of life (B), or receiving chemotherapy in the last 14 days of life (C). (D) Mean number of days spent as an inpatient in the last 30 days of life. (E) Mean cumulative Medicare spending in the last 30 days of life. Vertical error bars represent 95% confidence intervals (CIs). Adjusted risk ratios (RR) and means ratios are from multivariable models in the aggregate cohort of all histologies, adjusting for age, sex, race/ethnicity, socioeconomic status, comorbidities, performance status, survival from diagnosis, and temporal trends.