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O.O. Odejide et al.
cancer patients in the UK, those with myeloma (n=887) were significantly more likely to be referred to palliative care and less likely to die in acute care settings.37,38
Patients who survived more than a year after their diag- nosis were more likely to use hospice in a timely fashion and were also less likely to receive aggressive medical care close to death. This is consistent with prior data showing that survival duration is an important determinant of hav- ing a home versus hospital death.38 The relationship between survival time and EOL care may reflect increased patient experience with-and thus the desire to avoid-the burden of additional intensive treatments. Moreover, a longer time between diagnosis and death offers more opportunities to engage in advance care planning. Importantly, clear and consistent discussions regarding prognosis and EOL decision-making early in the disease trajectory are necessary if we are going to improve the quality of EOL care across all survival ranges.
We acknowledge limitations to our study. First, our cohort was restricted to patients 65 years and older who were enrolled in Medicare, which may limit the generaliz- ability of our findings. Nonetheless, we are reassured that the median diagnostic age for myeloma is well over 65 years. Second, we relied on claims to assess EOL care, which may have variable sensitivity in capturing out- comes of interest. Third, we did not have access to patients’ preferences, which are also a significant determi- nant of the quality of EOL care received. Next, we did not have access to Revised-International Staging System (R- ISS) stage for patients in this study, and thus could not determine if any association exists between R-ISS and EOL care. Finally, while each indicator of medically aggressive care near the EOL was equally weighted in our analysis as in previous studies,16,19,39 various stakeholders
(patients, hematologic oncologists, policy makers) may assign different levels of importance to each of the indica- tors.
In conclusion, our data suggest that along with vast improvements in treatment and survival, there has also been meaningful progress in EOL care for patients with myeloma in the USA. These patients are not only enrolling more often in hospice, but the increase in use is not driven by late enrollment. Still, there remains ample opportunity for further improvement, particularly among patients who survive less than one year, are dialysis- dependent, or transfusion-dependent. Possible solutions include earlier goals of care discussions, bridge palliative care services, and modification of the hospice model to enable transfusion support.
Funding
OOO received research support from the National Cancer Institute of the National Institutes of Health (NCI K08CA218295), National Palliative Care Research Center Career Development Award, and Harvard Medical School Office for Diversity Inclusion and Community Partnership Faculty Fellowship.
Acknowledgments
This study used the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, Centers for Medicare & Medicaid Services; Information Management Services, Inc.; and the SEER Program tumor registries in the creation of the SEER-Medicare database.
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