Receipt of specialized palliative care and health care utilization at the end of life in hematological cancer patients – the Stockholm experience
DOI:
https://doi.org/10.2340/1651-226X.2025.42189Keywords:
Observational study, Oncology, health care utilisation, End of life care, emergency room visits, quality indicatorsAbstract
Background: The treatments of hematological malignancies tend to be intense, and compared with solid tumors, less is known about the health care consumption during end of life (EOL). Therefore, the aim was to study the receipt of specialized palliative care (SPC) and how it affects health care utilization, in relation to sex, age, socioeconomics, and frailty risk (Hospital Frailty Risk Score [HFRS]).
Methods: In a retrospective, observational registry study, all patients who died of a hematological malignancy during the years 2015–2021 in the Stockholm County were included and analyzed with descriptive statistics and logistic regression models.
Results: Of the 2,858 included patients (mean age 76 years, 41% women), 38% had myeloid malignancies, 41% lymphocytic malignancies, and 21% had myeloma. During the last 3 months of life, 56% received SPC, with an overrepresentation of women, aOR 1.35 (1.16–1.58, p < 0.0001), whereas persons with risk of frailty (HFRS) were underrepresented, aOR 0.74 (0.63–0.86, p < 0.0001). Unplanned ER visits were more likely in persons aged over 80 years (p = 0.004) and in persons with frailty risk (p < 0.0001). Patients receiving SPC had a substantially reduced likelihood of ER visits, aOR 0.34 (0.29–0.40, p < 0.0001). Emergency hospitals as place of death was positively associated with frailty risk, aOR 1.50 (1.23–1.83, p < 0.0001) but negatively associated with age over 80 years (p < 0.0001) and especially with receipt of SPC, aOR 0.05 (0.04–0.06, p < 0.0001).
Interpretation: Receipt of SPC could possibly reduce the need for emergency care in the end of life and the Stockholm model might facilitate referral to SPC for hematological patients.
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References
Åhlin E. Cancer I Siffror 2023. 2023. Swedish National Board of Health and Welfare, Stockholm
Hemminki K, Hemminki J, Försti A, Sud A. Survival in hematological malignancies in the Nordic countries through a half century with correlation to treatment. Leukemia. 2023;37(4):854–63.
https://doi.org/10.1038/s41375-023-01852-w DOI: https://doi.org/10.1038/s41375-023-01852-w
Hill AD, Stukel TA, Fu L, Scales DC, Laupacis A, Rubenfeld GD, et al. Trends in site of death and health care utilization at the end of life: a population-based cohort study. CMAJ Open. 2019;7(2):E306–15.
https://doi.org/10.9778/cmajo.20180097 DOI: https://doi.org/10.9778/cmajo.20180097
Ma Z, Li H, Zhang Y, Zhang L, Huang G, Zhang Y, et al. Prevalence of aggressive care among patients with cancer near the end of life: a systematic review and meta-analysis. eClinicalMedicine. 2024;71:102561.
https://doi.org/10.1016/j.eclinm.2024.102561 DOI: https://doi.org/10.1016/j.eclinm.2024.102561
D’Amico TA, Bandini LAM, Balch A, Benson AB, Edge SB, Fitzgerald CL, et al. Quality Measurement in Cancer Care: A Review and Endorsement of High-Impact Measures and Concepts. J Natl Compr Canc Netw. 2020 Mar;18(3):250–259.
https://doi.org/10.6004/jnccn.2020.7536. PMID: 32135508. DOI: https://doi.org/10.6004/jnccn.2020.7536
Gebel C, Ditscheid B, Meissner F, Slotina E, Kruschel I, Marschall U, et al. Utilization and quality of palliative care in patients with hematological and solid cancers: a population-based study. J Cancer Res Clin Oncol. 2024;150(4):191.
https://doi.org/10.1007/s00432-024-05721-6 DOI: https://doi.org/10.1007/s00432-024-05721-6
Howell DA, Shellens R, Roman E, Garry AC, Patmore R, Howard MR. Haematological malignancy: are patients appropriately referred for specialist palliative and hospice care? A systematic review and meta-analysis of published data. Palliat Med. 2011;25(6):630–41.
https://doi.org/10.1177/0269216310391692 DOI: https://doi.org/10.1177/0269216310391692
Egan PC, LeBlanc TW, Olszewski AJ. End-of-life care quality outcomes among Medicare beneficiaries with hematologic malignancies. Blood Adv. 2020;4(15):3606–14.
https://doi.org/10.1182/bloodadvances.2020001767 DOI: https://doi.org/10.1182/bloodadvances.2020001767
Shaulov A, Aviv A, Alcalde J, Zimmermann C. Early integration of palliative care for patients with haematological malignancies. Br J Haematol. 2022;199(1):14–30.
https://doi.org/10.1111/bjh.18286 DOI: https://doi.org/10.1111/bjh.18286
The State of Myeloma in 2024 [Internet]. International Myeloma Foundation [cited 2024 Aug 05]. Available from: https://www.myeloma.org/blog/state-myeloma-2024
Moreau P, Garfall AL, Van de Donk NWCJ, Nahi H, San-Miguel JF, Oriol A, et al. Teclistamab in relapsed or refractory multiple myeloma. N Engl J Med. 2022;387(6):495–505.
https://doi.org/10.1056/NEJMoa2203478 DOI: https://doi.org/10.1056/NEJMoa2203478
Pak WLW, Brumwell NA, Kabel CC, Gutgarts V, Jaffer Sathick I, Mailankody S, et al. Chimeric antigen receptor (CAR) T-cell therapy use in patients with multiple myeloma and kidney failure on maintenance hemodialysis: A report of 2 cases. Kidney Med. 2024;6(8):100856.
https://doi.org/10.1016/j.xkme.2024.100856 DOI: https://doi.org/10.1016/j.xkme.2024.100856
McCaughan D, Roman E, Smith AG, Garry AC, Johnson MJ, Patmore RD, et al. Palliative care specialists’ perceptions concerning referral of haematology patients to their services: findings from a qualitative study. BMC Palliat Care. 2018;17(1):33.
https://doi.org/10.1186/s12904-018-0289-1 DOI: https://doi.org/10.1186/s12904-018-0289-1
Odejide OO, Salas Coronado DY, Watts CD, Wright AA, Abel GA. End-of-life care for blood cancers: A series of focus groups with hematologic oncologists. J Oncol Pract. 2014;10(6):e396–403.
https://doi.org/10.1200/JOP.2014.001537 DOI: https://doi.org/10.1200/JOP.2014.001537
Bigi S, Borelli E, Potenza L, Gilioli F, Artioli F, Porzio G, et al. Early palliative care for solid and blood cancer patients and caregivers: quantitative and qualitative results of a long-term experience as a case of value-based medicine. Front Public Health. 2023;11:1092145.
https://doi.org/10.3389/fpubh.2023.1092145 DOI: https://doi.org/10.3389/fpubh.2023.1092145
El-Jawahri A, LeBlanc T, VanDusen H, Traeger L, Greer JA, Pirl WF, et al. Effect of inpatient palliative care on quality of life 2 weeks after hematopoietic stem cell transplantation: a randomized clinical trial. JAMA. 2016;316(20):2094–103.
https://doi.org/10.1001/jama.2016.16786 DOI: https://doi.org/10.1001/jama.2016.16786
LeBlanc TW, O’Donnell JD, Crowley-Matoka M, Rabow MW, Smith CB, White DB, et al. Perceptions of palliative care among hematologic malignancy specialists: A mixed-methods study. J Oncol Pract. 2015;11(2):e230–8.
https://doi.org/10.1200/JOP.2014.001859 DOI: https://doi.org/10.1200/JOP.2014.001859
Strang P, Schultz T. The impact of frailty on palliative care receipt, emergency room visits and hospital deaths in cancer patients: A registry-based study. Curr Oncol Tor Ont. 2023;30(7):6623–33.
https://doi.org/10.3390/curroncol30070486 DOI: https://doi.org/10.3390/curroncol30070486
MosaicTM | Livsstilsbaserad segmentering [Internet]. InsightOne. [cited 2024 Oct 4]. Available from: https://insightone.se/mosaic/
Wami WM, Dundas R, Molaodi OR, Tranter M, Leyland AH, Katikireddi SV. Assessing the potential utility of commercial ‘big data’ for health research: Enhancing small-area deprivation measures with ExperianTM Mosaic groups. Health Place. 2019;57:238–46.
https://doi.org/10.1016/j.healthplace.2019.05.005 DOI: https://doi.org/10.1016/j.healthplace.2019.05.005
Bergqvist J, Hedman C, Schultz T, Strang P. Equal receipt of specialized palliative care in breast and prostate cancer: a register study. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2022;30(9):7721–30.
https://doi.org/10.1007/s00520-022-07150-y DOI: https://doi.org/10.1007/s00520-022-07150-y
Strang P, Fürst P, Hedman C, Bergqvist J, Adlitzer H, Schultz T. Chronic obstructive pulmonary disease and lung cancer: access to palliative care, emergency room visits and hospital deaths. BMC Pulm Med. 2021;21(1):170.
https://doi.org/10.1186/s12890-021-01533-3 DOI: https://doi.org/10.1186/s12890-021-01533-3
Gilbert T, Neuburger J, Kraindler J, Keeble E, Smith P, Ariti C, et al. Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study. Lancet Lond Engl. 2018;391(10132):1775–82.
https://doi.org/10.1016/S0140-6736(18)30668-8 DOI: https://doi.org/10.1016/S0140-6736(18)30668-8
Verhoef MJ, De Nijs EJM, Ootjers CS, Fiocco M, Fogteloo AJ, Heringhaus C, et al. End-of-life trajectories of patients with hematological malignancies and patients with advanced solid tumors visiting the emergency department: The need for a proactive integrated care approach. Am J Hosp Palliat Care. 2020;37(9):692–700.
https://doi.org/10.1177/1049909119896533 DOI: https://doi.org/10.1177/1049909119896533
Cowan AJ, Green DJ, Kwok M, Lee S, Coffey DG, Holmberg LA, et al. Diagnosis and management of multiple myeloma: a review. JAMA. 2022;327(5):464–77.
https://doi.org/10.1001/jama.2022.0003 DOI: https://doi.org/10.1001/jama.2022.0003
Jacobsen E. Follicular lymphoma: 2023 update on diagnosis and management. Am J Hematol. 2022;97(12):1638–51.
https://doi.org/10.1002/ajh.26737 DOI: https://doi.org/10.1002/ajh.26737
Kantarjian HM, Kadia TM, DiNardo CD, Welch MA, Ravandi F. Acute myeloid leukemia: Treatment and research outlook for 2021 and the MD Anderson approach. Cancer. 2021;127(8):1186–207.
https://doi.org/10.1002/cncr.33477 DOI: https://doi.org/10.1002/cncr.33477
Sehn LH, Salles G. Diffuse Large B-Cell Lymphoma. N Engl J Med. 2021;384(9):842.
https://doi.org/10.1056/NEJMra2027612 DOI: https://doi.org/10.1056/NEJMra2027612
Hui D, Didwaniya N, Vidal M, Shin SH, Chisholm G, Roquemore J, et al. Quality of end-of-life care in patients with hematologic malignancies: a retrospective cohort study. Cancer. 2014;120(10):1572–8.
https://doi.org/10.1002/cncr.28614 DOI: https://doi.org/10.1002/cncr.28614
Rao VB, Belanger E, Egan PC, LeBlanc TW, Olszewski AJ. Early palliative care services and end-of-life care in Medicare beneficiaries with hematologic malignancies: A population-based retrospective cohort study. J Palliat Med. 2021;24(1):63–70.
https://doi.org/10.1089/jpm.2020.0006 DOI: https://doi.org/10.1089/jpm.2020.0006
Scacchi A, Savatteri A, Politano G, Conti A, Dalmasso M, Campagna S, et al. Impact of the timing of integrated home palliative care enrolment on emergency department visits. Int J Health Policy Manag. 2022;11(12):2964–71.
https://doi.org/10.34172/ijhpm.2022.5783 DOI: https://doi.org/10.34172/ijhpm.2022.5783
Strang P, Schultz T, Ozanne A. Partly unequal receipt of healthcare in last month of life in amyotrophic lateral sclerosis: a retrospective cohort study of the Stockholm region. Ups J Med Sci. 2024;129:e9856..
https://doi.org/10.48101/ujms.v129.9856 DOI: https://doi.org/10.48101/ujms.v129.9856
Lustbader D, Mudra M, Romano C, Lukoski E, Chang A, Mittelberger J, et al. The impact of a home-based palliative care program in an accountable care organization. J Palliat Med. 2017;20(1):23–8.
https://doi.org/10.1089/jpm.2016.0265 DOI: https://doi.org/10.1089/jpm.2016.0265
Gitau K, Huang A, Isenberg SR, Stall N, Ailon J, Bell CM, et al. Association of patient sex with use of palliative care in Ontario, Canada: a population-based study. CMAJ Open. 2023;11(6):E1025–32.
https://doi.org/10.9778/cmajo.20220232 DOI: https://doi.org/10.9778/cmajo.20220232
Fürst P, Strang P, Hedman C, Schultz T. Advanced cancer and concomitant dementia: access to specialized palliative care, emergency room, hospital care, and place of death. Acta Oncol Stockh Swed. 2022;61(7):874–80.
https://doi.org/10.1080/0284186X.2022.2062681 DOI: https://doi.org/10.1080/0284186X.2022.2062681
Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013;2013(6):CD007760.
https://doi.org/10.1002/14651858.CD007760.pub2 DOI: https://doi.org/10.1002/14651858.CD007760.pub2
Nordström M, Strang P. High degree of satisfaction with the support given by multidisciplinary palliative home care teams in the county of Stockholm. J Palliat Care. 2018;33(2):109–14.
https://doi.org/10.1177/0825859718759880 DOI: https://doi.org/10.1177/0825859718759880
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Copyright (c) 2025 Lena von Bahr, Peter Strang, Torbjörn Schultz, Per Fürst
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