Page 144 - Haematologica August 2018

Correspondence:
oreofe_odejide@dfci.harvard.edu
Received: January 4, 2018. Accepted: May 3, 2018. Pre-published: May 10, 2018.
doi:10.3324/haematol.2018.187609
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Ferrata Storti Foundation
Quality of Life
Meaningful changes in end-of-life care among patients with myeloma
Oreofe O. Odejide,1,2 Ling Li,1 Angel M. Cronin,1 Anays Murillo,1 Paul G. Richardson,3 Kenneth C. Anderson3 and Gregory A. Abel1,4
1Division of Population Sciences; 2Center for Lymphoma; 3Center for Myeloma and 4Center for Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
ABSTRACT
Patients with advanced myeloma experience a high symptom burden particularly near the end of life, making timely hospice use crucial. Little is known about the quality and determinants of end-of-life care for this population, including whether potential increases in hospice use are also accompanied by “late” enrollment (≤ 3 days before death). Using the Surveillance, Epidemiology, and End-Results-Medicare data- base, we identified patients ≥ 65 years diagnosed with myeloma between 2000 and 2013 who died by December 31, 2013. We assessed prevalence and trends in hospice use, including late enrollment. We also examined six established measures of potentially aggressive medical care at the end of life. Independent predictors of late hospice enrollment and aggressive end-of-life care were assessed using multivariable logistic regression analyses. Of 12,686 myeloma decedents, 48.2% enrolled in hospice. Among the 6111 who enrolled, 17.2% spent ≤ 3 days there. There was a significant trend in increasing hospice use, from 28.5% in 2000 to 56.5% by 2013 (Ptrend <0.001), no significant rise in late enroll- ment (12.2% in 2000 to 16.3% in 2013, Ptrend =0.19), and a slight decrease in aggressive end-of-life care (59.2% in 2000 to 56.7% in 2013, Ptrend =0.01). Patients who were transfusion-dependent, on dialysis, or sur- vived for less than one year were more likely to enroll late in hospice and experience aggressive medical care at the end of life. Gains in hospice use for myeloma decedents were not accompanied by increases in late enrollment or aggressive medical care. These findings suggest meaningful improvements in end-of-life care for this population.
Introduction
Multiple myeloma is a hematologic cancer diagnosed in over 30,000 individuals each year in the USA.1 It is predominantly a disease of older adults, with a median age of diagnosis at 69 years.2 Although there has been a rapid adoption of novel treatments leading to improvements in survival, myeloma remains an incurable disease.3-6 Moreover, affected patients experience substantial symptom burden throughout the disease trajectory, which intensifies near the end of life (EOL).7,8 Accordingly, high-quality EOL care is crucial for this population.
Hospice is a model of care that has been demonstrated to be effective in allevi- ating patient suffering and improving quality of life for patients near the EOL, through the provision of expert symptom-directed care.9,10 Although hospice enrollment in the USA typically involves discontinuation of chemotherapy and transfusions, this is not the case for many hospice programs in European countries.11 Despite these differences in hospice care delivery in various locations, the central focus is to improve patient quality of life through expert symptom- directed care. In contrast to hospice, medically aggressive care near the EOL is associated with worse patient quality of life.12 Moreover, bereaved caregivers of patients who receive aggressive medical care close to death are less likely to report that their loved ones received “excellent” care, and are also at heightened risk of poor mental health outcomes.9,13 Timely hospice enrollment and avoidance of aggressive medical care near death (e.g., multiple hospitalizations or intensive care
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