Factors associated with intensity of end-of-life care for patients with acute myeloid leukemia
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INTRODUCTION: Older patients with AML (> 60 years) often receive intensive EOL care including hospitalizations and chemotherapy close to death. Intensive EOL care has been shown to increase emotional and financial burdens for patients and families, while often not aligning with patients’ preferences. However, factors associated with the intensity of EOL care in this population are unknown. OBJECTIVES: There is a need to better understand the factors associated with intense EOL care, in hopes of providing more informed, high-quality EOL care in line with patient preferences and decreasing burdens associated with unnecessary healthcare. We aim to describe the associations between the intensity of EOL care, patient demographics, and baseline psychological distress in older patients with AML. METHODS: We conducted a secondary analysis of two supportive care studies including 168 deceased older patients with AML. We assessed patients’ demographics, quality of life (QOL) [Functional Assessment Cancer Therapy-Leukemia], and anxiety and depression symptoms [Hospital Anxiety and Depression Scale (HADS); Patient Health Questionnaire (PHQ-9)] at the time of diagnosis. We used multivariate logistic regression models to examine the association among 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 69 (range 20-100), and the majority were males (63.7% 107/168). 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, and 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]. Patients factors were not associated with hospice utilization. CONCLUSIONS: Older patients with AML who are more educated and report elevated depression symptoms and lower QOL at the time of diagnosis were more likely to receive intensive EOL care. These findings identify a population at the time of diagnosis of AML who are at higher risk for hospitalizations and chemotherapy use at the EOL and who may benefit from targeted supportive care interventions.
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