HOME CARE FOR UNFIT ELDERLY PATIENTS WITH MYELODISPLASTIC SYNDROMES:
                AN ITALIAN SINGLE-CENTER EXPERIENCE
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EHA 2009

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"Home care for unfit elderly patients with myelodisplastic syndromes:an Italian single-center experience. "Poster presented at the 14th Congress of EHA (Berlin, 2009)".

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EHA 2009

  1. 1. HOME CARE FOR UNFIT ELDERLY PATIENTS WITH MYELODISPLASTIC SYNDROMES: AN ITALIAN SINGLE-CENTER EXPERIENCE Pierluigi Alfieri *, Leonardo Ferrara °, Giovanna Leonardi °, Mario Luppi °, Roberto Marasca °, Giuseppe Torelli °, Enzo Favale * * Hematology Home Care Service, AIL Modena Onlus and ° Modena University Hospital, Department of Oncology and Hematology Background Myelodisplastic syndromes (MDS) are an heterogeneous group of bone marrow disorders, with a higher incidence in old age. In the elderly setting main clinical needs are transfusion support and regular follow-up appointments, commonly provided on outpatient basis, often resulting in discomfort arising from driving distances and long waiting times. Hospital admissions, usually due to worsening of comorbities and infectious events, are also frequent. In our department a home care (HC) service sustained by the fundraising organization A.I.L. (Italian Association against Leukemia-Lymphoma- Myeloma) is active in order to manage fragile hematology patients outside the standard in-hospital assistance, to improve their quality of life and optimize healthcare resources. Here we describe our experience in 40 consecutive elderly patients with MDS referred to a domiciliary service of supportive care in the period 2000-2008. Methods MDS diagnosis was formulated according to WHO classifications. The Severity of Illness Index was calculated to evaluate the impact of comorbidities. All 40 patients fulfilled inclusion criteria for HC (poor performance status, appropriate home logistics, caregiver availability, distance from hospital ≤ 30 km). Home transfusions were requested on the basis of hemoglobin levels (Hb ≤ 8 g/dL) and platelet count (PLT ≤ 10.000/mcl) and/or in presence of symptoms related to anaemia and thrombocytopenia. HC duration, generally corresponding to the remaining lifetime, was compared among different patients’ groups divided by age, MDS subtype and comorbidity burden. A.I.L. HEMATOLOGY HOME CARE SERVICE Category No. of patients Median age Median no. of severe comorbidities HC duration Hematologist Specialist Nurse All MDS patients 40 83.3 years 1.57 309 days RA 22 85.5 1.63 285 HOME Patient RARS 2 81.5 1.51 284 Family RAEB-1 4 79.7 1.25 450 Caregiver RAEB-2 7 78.4 1.43 212 UNIVERSITY HOSPITAL COMMUNITY HEALTH TRUST Division of Hematology General Practitioners CMML 5 82.0 1.80 233 Blood Bank Community Nurses Age ≤ 80 14 75.1 1.50 301 Central Clinical Laboratory On-call Doctors Hospice Pharmacy Age ≥ 81 26 87.7 1.62 272 440 hematology patients have been referred to this service Comorbidity ≤ 1 21 82.9 1.00 417 from July 1999 to May 2009 20 km Around 2500 transfusions and 100 chemotherapy cycles Comorbidities ≥ 2 19 83.7 2.21 146 have been provided at home Results Median age was 83 years (range 64-97), with 70% of patients aged ≥ 80 years. Gender was equally distributed (19 male, 21 female). 22 patients presented refractory anaemia (RA), 2 patients had refractory anaemia with ring sideroblasts (RARS); refractory anaemia with excess of blasts type 1 (RAEB-1) and type 2 (RAEB-2) were respectively diagnosed in 4 and 7 patients. 5 patients with chronic myelomonocytic leukemia (CMML) were also included in this report. 15 out of 40 patients (37.5%) developed leukemic transformation. The median number of severe non-hematologic comorbidities was 1.57, with prevalence of cardiac and pulmonary diseases. Median duration of HC was 309 days, with significant differences only according to the number of severe comorbidities (417 days if ≤ 1, 146 days if ≥ 2). Home transfusion support was provided, without relevant adverse events, in 26 patients (65%), for a total of 385 units of packed red blood cells and 92 of platelet concentrates. 27 patients (67.5%) were admitted as inpatients for a total of 44 hospital admissions, mainly caused by cardiac failure, severe infections, caregivers’ burn-out and end-of-life care. Summary In our operating model HC for unfit elderly patients affected by myelodisplastic syndromes is feasible, sustainable and safe. Severe comorbidities are correlated with poorer survival, irrespective of MDS subtype and age distribution. HC represents a valid resource to implement the management of patients with blood malignancies, especially if there is a consultant hematologist fully dedicated to domiciliary patients, allowing an efficient integration among hospital division, general practitioners and community health services. Cost- effectiveness analysis and economic recognition in public health systems are some of the open issues to be shortly explored. References and Acknoledgements Author Contacts Greenfield S., Development and testing of a new index of comorbidity, Clinical Research, 1987 Dr. Pierluigi Alfieri (Email: pierluigi.alfieri@unimore.it – Phone: +39.059.4223260 – Fax: +39.059.4223417) Niscola P., Home care management of patients affected by hematologic malignancies, Haematologica, 2006 Servizio di Assistenza Domiciliare Ematologica AIL – Divisione di Ematologia – Policlinico di Modena Rozzini R., Geriatrics Index of Comorbidity, Age and Ageing, 2002 Via del Pozzo, 71 – 41124 Modena – Italy A special thanks goes to the nurses and patients’ families involved in the daily routine of actual caregiving, and to the volunteers and donors participating in fundraising events of the local section of A.I.L. (Italian Association against Leukemia-Lymphoma-Myeloma).

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