Factors Associated with High Healthcare Utilization at the End-of-Life (EOL) for Patients with Acute Myeloid Leukemia

INTRODUCTION: High rates of healthcare utilization at the EOL have been shown to negatively impact patients' quality-of-life (QOL), psychological distress, and caregivers' bereavement outcomes. Older patients (> 60 years) with acute myeloid leukemia (AML) often experience high healthcare utilization at the EOL, including hospitalizations and chemotherapy close to death. Yet, factors associated with healthcare utilization at the EOL in this population are unknown.

METHODS: We conducted a secondary analysis of two supportive care studies including 168 deceased older patients with AML. We assessed patients' demographics, QOL [Functional Assessment Cancer Therapy-Leukemia], and psychological distress [Hospital Anxiety and Depression Scale (HADS); Patient Health Questionnaire (PHQ-9)] at diagnosis. We used multivariate logistic regression models to examine the associations between demographic factors, patient-reported outcomes, and the following EOL care outcomes abstracted from the electronic health record: 1) hospitalizations in the last 7 days of life; 2) receipt of chemotherapy in the last 30 days of life; and 3) hospice utilization.

RESULTS: The median age of the cohort was 67 (range 20-100), and the majority identified as male (63.7% - 107/168) and white (88.1% - 148/168). Overall, 66.7% (110/165) of patients were hospitalized in the last 7 days of life, 51.8% (71/137) received chemotherapy in the last 30 days of life, 59.5% (100/168) died in the hospital, while 40.7% (70/168) utilized hospice services. In multivariate models, higher education (OR = 1.54, SE=0.24, P=0.006), and elevated depression symptoms (PHQ-9: OR=1.09, SE=0.04, P=0.028) at the time of diagnosis were associated with higher odds of being hospitalized in the last 7 days of life. In contrast, higher QOL at diagnosis (OR=0.98, SE=0.01, P=0.009) was associated with lower odds of being hospitalized in the last 7 days of life. Depression symptoms at the time of diagnosis as measured by the HADS was the only factor associated with the receipt of chemotherapy in the last 30 days of life (HADS-Depression: OR=1.10, SE=0.05, P=0.042). Patient-reported factors, including demographics, QOL, and psychological distress, were not associated with hospice utilization.

CONCLUSIONS: Older patients with AML who reported higher levels of education, elevated depression symptoms, and lower QOL at the time of diagnosis were more likely to experience intense healthcare utilization at the EOL. These findings identify an AML population who are at higher risk for hospitalizations and additional chemotherapy at the EOL, and who may benefit from targeted interventions to optimize their EOL care.