Does Nonresponse Bias the Results of Retrospective Surveys of End-of-Life Care?
ABSTRACT To evaluate the effect of nonresponse bias on reports of the quality of end-of-life care that older adults receive.
Nationwide retrospective survey of end-of-life care.
Sixty-two Veterans Affairs Medical Centers.
Patients were eligible if they died in a participating facility. One family member per patient was selected from medical records and invited to participate.
The telephone survey included 14 items describing important aspects of the patient's care in the last month of life. Scores (0-100) reflect the percentage of items for which the family member reported that the patient received the best possible care, and a global item defined the proportion of families who said the patient received "excellent" care. To examine the effect of nonresponse bias, a model was created to predict the likelihood of response based on patient and family characteristics; then this model was used to apply weights that were equivalent to the inverse of the probability of response for that individual.
Interviews were completed with family members of 3,897 of 7,110 patients (55%). Once results were weighted to account for nonresponse bias, the change in mean individual scores was 2% of families reporting "excellent" care. Of the 62 facilities in the sample, the scores of only 19 facilities (31%) changed more than 1% in either direction, and only 10 (16%) changed more than 2%.
Although nonresponse bias is a theoretical concern, it does not appear to have a significant effect on the facility-level results of this retrospective family survey.
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ABSTRACT: Context The Veterans Health Administration (VA) has improved the quality of end-of-life (EOL) care over the past several years. Several structural and process variables are associated with better outcomes. Little is known, however, about the relationship between the organization of nursing care and EOL outcomes. Objectives To examine the association between the organization of nursing care, including the nurse work environment and nurse staffing levels, and quality of EOL care in VA acute care facilities. Methods Secondary analysis of linked data from the Bereaved Family Survey (BFS), electronic medical record, administrative data, and the VA Nursing Outcomes Database. The sample included 4908 Veterans who died in one of 116 VA acute care facilities nationally between October 2010 - September 2011. Unadjusted and adjusted generalized estimating equations were used to examine associations between nursing and BFS outcomes. Results BFS respondents were 17% more likely to give an “excellent” overall rating of the quality of EOL care received by the veteran in facilities with better nurse work environments (P<0.05). The nurse work environment also was a significant predictor of providers listening to concerns and providing desired treatments. Nurse staffing was significantly associated with an “excellent” overall rating, alerting of the family prior to death, attention to personal care needs, and the provision of emotional support after the patient’s death. Conclusion Improvement of the nurse work environment and nurse staffing in VA acute care facilities may result in enhanced quality of care received by hospitalized veterans at the EOL.Journal of Pain and Symptom Management 08/2014; 63(2). DOI:10.1016/j.jpainsymman.2014.07.002 · 2.74 Impact Factor
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ABSTRACT: Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care. To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement. We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care VA facilities between 2010-2011. Outcomes included: 1) palliative care consult; 2) chaplain visit; and 3) death in an inpatient hospice/palliative care unit. We also assessed DNR orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice/palliative care unit death, and DNR, we additionally adjusted for palliative care consults. Mean (SD) age was 74(± 12) years, 98% were men, and 19% were non-White. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative consult, AOR 4.31 (95% CI 3.90-4.76), a chaplain visit, AOR 1.18 (95% CI 1.07-1.31), and a DNR order, AOR 4.59 (95% CI 4.08-5.16), but not more likely to die in a hospice/palliative care unit. Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit, and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.Journal of pain and symptom management 05/2014; DOI:10.1016/j.jpainsymman.2014.04.001 · 2.74 Impact Factor
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ABSTRACT: Background In 2009 two randomised cluster trials took place to assess the introduction of the Italian Version of the Liverpool Care Pathway in hospitals and hospices. Before and after data were gathered. The primary aim of this study is to evaluate the feasibility of using a combination of assessment methods aimed at different proxy respondents to create a means of measuring quality of care at the end of life. We also aim to explore whether there are differences in response to this approach between the hospice and hospital inpatient settings. Methods A retrospective design was used. Eligible deaths were traced through death registries, and proxies were used to give information. Four procedures of assessment were used to measure different dimensions. Feasibility was assessed through compliance and adherence to the study instruments, and measured against standards derived from previous after-death studies. The proxy caregiver's rating of the study tools was also measured, to gauge feasibility and effectiveness. All consecutive cancer deaths that occurred in the study period were eligible. In both trials, deaths were excluded if the patient was a relative of hospital/hospice staff. 145 patients were recruited from the Hospital setting, and 127 from Hospice. Results A high proportion of non-professional caregivers were interviewed - in both hospital (76.6%) and hospice (74.8%). There was no significant difference in the median number of days in each setting. 89.0% of hospital patients' GPs and 85.0% of hospice patients' GPs were interviewed. Care procedures were recorded in all hospice cases, and were missing in only 1 hospital case.52.7% of Hospital patients' relatives and 64.12% Hospice relatives were assessed to have been caused a low level of distress through the study. Conclusions The data shows high levels of compliance and adherence to the study instruments. This suggests that this approach to assessing quality of care is feasible, and this coupled with low levels of distress caused by the study instruments suggest effectiveness. There were no substantial differences between the hospice and hospital settings.BMC Palliative Care 07/2014; 13(36). DOI:10.1186/1472-684X-13-36 · 1.79 Impact Factor