Demographic Characteristics and Mortality Trends in Jehovah's Witnesses Patients with Chemotherapy-Induced Anemia Treated with Erythropoietin-Stimulating Agents: Analysis of the National Inpatient Sample (NIS) Database
Authors: Gaddam Mrunanjali , Sinha Samridhi , Sanka Sujana , Iqbal Rabia , Kavuri Swathi , Jayakumar Jayalekshmi , Colon Ramos Ana , Singh Surbhi , Atluri Sobha , Koifman Michelle , Ullah Asmat 
Published: December 2024

Introduction:
Jehovah's Witnesses may choose to refuse the administration of red blood cell transfusions based on deeply held religious beliefs, presenting a unique challenge in managing anemia, especially when these patients have underlying advanced malignancy and have anemia induced by chemotherapy. Clinicians must respect Jehovah's Witness patient's preferences and use other treatment modalities when managing these patients without administering red blood cell transfusion to treat symptomatic anemia so as not to offend their religious beliefs. Severe anemia has poor outcomes in terms of increased mortality and morbidity such as heart failure, shock and ICU admission. Erythropoietin stimulating agents (ESAs) offer an excellent alternative by promoting erythropoiesis. Our Study aimed to investigate the demographic characteristics and mortality trends in Jehovah's Witnesses (JW) Patients with Chemotherapy-Induced Anemia hospital admissions who received ESAs to better understand the effectiveness of ESAs and their impact on this specific patient group.
Methods:
We queried the National Inpatient Sample database from 2016 - 2020 to identify adult hospitalizations (age &gt; 18) with a diagnosis of Jehovah's Witness with chemotherapy-induced anemia (JW with CIA) using appropriate ICD 10 codes. This population was further divided into two cohorts: those treated with ESAs and those not treated with ESAs. A Retrospective cohort study was conducted to identify patient demographics such as age, gender, race/ethnicity and Mortality trends over the years. Categorical variables were compared using the chi-square test and continuous variables with the t-test.
Results:
We found a total of 63,024 Jehovah's Witness (JW) adult hospitalizations, of which 0.8 % (50,419) hospitalizations received ESAs in the setting of chemotherapy-induced anemia (CIA).
The mean age of JW with CIA patients who received ESAs is 62 years, of which 66% are females and 34% are males. JW patients with CIA Hospitalizations who received ESAs are more common among African Americans (43.8%) compared to Whites (35.2%), Hispanics (17.1%) and other races (3.9%). The predominant types of insurance coverage for these hospitalizations were Medicare (55%), private insurance (28.3%), and Medicaid (13.4%). Most hospitalizations (96%) took place in urban settings, with 55.7% occurring in large hospitals (300+ beds), 36.8% in medium-sized hospitals (100-200 beds), and only 7.5% in small hospitals (fewer than 100 beds). The mortality rate of JW patients with CIA hospitalizations who received ESAs increased overall even though it fluctuated over the study period: 7% in 2016, decreased to 5% in 2017, significantly increased to 10% in 2018, peaked at 40% in 2019, and decreased to 7.6% in 2020.
Conclusion:
Our study reveals an overall increasing trend in the mortality rates over years of Jehovah's Witness patients with chemotherapy-induced anemia despite receiving the erythropoietin stimulating agents (ESAs). The demographic analysis shows that, even though these hospitalizations were to urban hospitals and primarily large facilities with extensive resources, the mortality rates have risen over the years. Clinicians can use the identified demographic patterns to better assess and manage risk in JW patients with CIA who are on ESAs. Our study aims to stress increasing vigilance in this vulnerable cohort and the importance of proactive measures to prevent worse outcomes. Additional research is needed to guide strategies for preventing, detecting, and managing complications and comorbidities in this patient population.