Transfusion dependence, use of hospice services, and quality of end-of-life care in leukemia.

Hospice provides high-quality end-of-life care, but patients with leukemias use hospice services less frequently than those with solid tumors. Transfusion dependence (TD) may hinder or delay enrollment, because hospice organizations typically disallow transfusions. We examined the association between TD and end-of-life outcomes among Medicare beneficiaries with leukemia. From the Surveillance, Epidemiology, and End Results-Medicare database, we selected beneficiaries with acute and chronic leukemias who died in 2001-2011. We defined TD as ≥2 transfusions within 30 days before death or hospice enrollment. End points included hospice enrollment and length of stay, reporting relative risk (RR) adjusted for key covariates. Among 21 033 patients with a median age of 79 years, 20% were transfusion dependent before death/hospice enrollment. Use of hospice increased from 35% in 2001 to 49% in 2011. Median time on hospice was 9 days and was shorter for transfusion-dependent patients (6 vs 11 days; < .001). Adjusting for baseline characteristics, TD was associated with a higher use of hospice services (RR, 1.08; 95% confidence interval [CI], 1.04-1.12) but also with 51% shorter hospice length of stay (RR, 0.49; 95% CI, 0.44-0.54). Hospice enrollees had a lower likelihood of inpatient death and chemotherapy use and lower median Medicare spending at end-of-life, regardless of TD status. In conclusion, relatively increased hospice use combined with a markedly shorter length of stay among transfusion-dependent patients suggests that they have a high and incompletely met need for hospice services and that they experience a barrier to timely referral. Policy solutions supporting palliative transfusions may maximize the benefits of hospice for leukemia patients.