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ABSTRACT: Growing attention to end-of-life care has led to intensive efforts to provide better palliative care. However, it is not known whether palliative care is best provided by consultative teams or in dedicated units.
This nationwide telephone survey was conducted in 77 Veterans Affairs medical centers that offer palliative care consultation services and dedicated palliative care units. One family member per patient who died at a participating Veterans Affairs medical center between July 1, 2008, and December 31, 2009, was invited to participate. The telephone survey included 1 global rating item and 9 core items describing the patient's care in the last month of life.
Interviews were completed with family members for 5901 of 9546 patients. Of these, 1873 received usual care, 1549 received a palliative care consultation, and 2479 received care in a palliative care unit. After nonresponse weighting and propensity score adjustment, families of patients who received a palliative care consultation were more likely than those who received usual care to report that the patient's care in the last month of life had been "excellent" (adjusted proportions: 51% vs 46%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.02-1.55; P = .04). However, families of patients who received care in a palliative care unit were even more likely to report excellent care (adjusted proportions: 63% vs 53%; OR, 1.52; 95% CI, 1.25-1.85; P < .001).
Care received in palliative care units may offer more improvements in care than those achieved with palliative care consultations.
Archives of internal medicine 04/2011; 171(7):649-55. · 11.46 Impact Factor
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ABSTRACT: The goal of this study was to define families' priorities for various aspects of end-of-life care, and to determine whether scores that reflect these priorities alter facilities' quality rankings.
Nationwide telephone survey.
62 VA medical centers, including acute and long term care.
For each patient who died in a participating facility, one family member was invited to participate.
A survey included 14 items describing key aspects of the patient's care in his or her last month of life, and one global rating. A weighted score was calculated based on the association between each item and the global rating.
Interviews were completed with family members for 3,897 of 7,110 patients (55%). Items showed an approximately 5-fold range of weights, indicating a wide variation in the importance that families placed on aspects of palliative care (low: pain management, weight = 0.54, 95% CI 0.38-0.70;/P/<0.001; high: providers were "kind, caring, and respectful: weight = 2.46, 95% CI 2.24-2.68;/P/<0.001). Weights were homogeneous across patient subgroups, and there were no significant changes in facilities' quality rankings when weights were used. Both weighted and unweighted scores showed similar evidence of the impact of process measures.
There appears to be wide variation in the importance that families place on several aspects of end-of-life care. However, the impact of weighting was generally even across patient subgroups and facilities. Therefore, the use of weights to account for families' priorities is not likely to alter a facility's quality score.
Journal of palliative medicine 02/2011; 14(3):301-7. · 1.84 Impact Factor
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ABSTRACT: Because the Family Evaluation of Treatment at End of Life (FATE) survey was too long for routine use in the Veterans Administration (VA) health care system to measure quality of care, a shorter instrument was developed.
To evaluate the short version of the FATE survey for use as a nationwide quality measure in the VA health care system.
Fifty-one VA medical centers, including acute and long-term care, participated in this nationwide telephone survey. Family members of the patients were eligible if the patients died in a participating facility. One family member per patient was selected from medical records using predefined eligibility criteria and invited to participate. The survey consists of 14 items describing key aspects of the patient's care in his or her last month of life, one global rating, and two open-ended questions for additional comments.
Interviews were completed with 2827 family members. Overall, the survey showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach's α=0.84) and strong evidence of discriminant validity. Two survey items have been targeted for quality improvement efforts in multisite collaboratives.
Surveys of surrogates offer an important source of quality data that can be used to improve the quality of end-of-life care and promote accountability.
Journal of pain and symptom management 12/2010; 40(6):801-9. · 2.42 Impact Factor
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Archives of internal medicine 11/2010; 170(20):1856-7. · 11.46 Impact Factor
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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.
Journal of the American Geriatrics Society 11/2010; 58(12):2381-6. · 3.74 Impact Factor
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ABSTRACT: The Veterans Affairs (VA) has made significant investments in care for veterans. However, it is not known whether these investments have produced improvements in end-of-life care in the VA compared to other settings. Therefore, the goal of this study was to compare families' perceptions of end-of-life care among patients who died in VA and non-VA facilities.
Retrospective 32-item telephone surveys were conducted with family members of patients who died in VA and non-VA facilities.
Five Veterans Affairs medical centers and their affiliated nursing homes and outpatient clinics.
Patients were eligible if they received any care from a participating VA facility in the last month of life and if they died in an inpatient setting. One family member per patient completed the survey.
In bivariate analysis, patients who died in VA facilities (n = 520) had higher mean satisfaction scores compared to those who died in non-VA facilities (n = 89; 59 versus 51; rank sum test p = 0.002). After adjusting for medical center, the overall score was still significantly higher for those dying in the VA (beta = 0.07; confidence interval [CI] = 0.02-0.11; p = 0.004), as was the domain measuring care around the time of death (beta = 0.11; CI = 0.04-0.17; p = 0.001).
Families of patients who died in VA facilities rated care as being better than did families of those who died in non-VA facilities. These results provide preliminary evidence that the VA's investment in end-of-life care has contributed to improvements in care in VA facilities compared to non-VA facilities.
Journal of palliative medicine 08/2010; 13(8):991-6. · 1.84 Impact Factor
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ABSTRACT: To define the frequency of post-traumatic stress disorder (PTSD)-related symptoms among veterans who are near the end of life and to describe the impact that these symptoms have on patients and their families.
Patients had received inpatient or outpatient care from a participating VA facility in the last month of life, and one family member per patient was selected using predefined eligibility criteria. Family members then completed a telephone survey, The Family Assessment of Treatment at End-of-Life, which assessed their perceptions of the quality of the care that the patients and they themselves received during the patients' last month of life.
Seventeen percent of patients (89 of 524) were reported to have had PTSD-related symptoms in the last month of life. PTSD-related symptoms caused discomfort less often than pain did (mean frequency score 1.79 vs. 1.93; Wilcoxon sign rank test, P<0.001) but more often than dyspnea did (mean severity score 1.79 vs. 1.73; Wilcoxon sign rank test, P<0.001). Family members of patients with PTSD-related symptoms reported less satisfaction overall with the care the patient received (mean score 48 vs. 62; rank sum test, P<0.001). Patients who received a palliative care consult (n=49) had lower ratings of discomfort attributed to PTSD-related symptoms (mean 1.55 vs. 2.07; rank sum test, P=0.007).
PTSD-related symptoms may be common and severe among veterans near the end of life and may have a negative effect on families' perceptions of the quality of care that the veteran received.
Journal of pain and symptom management 03/2010; 39(3):507-14. · 2.42 Impact Factor
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ABSTRACT: Background
Growing attention to end-of-life care has led to intensive efforts to provide better palliative care. However, it is not known whether palliative care is best provided by consultative teams or in dedicated units.Methods
This nationwide telephone survey was conducted in 77 Veterans Affairs medical centers that offer palliative care consultation services and dedicated palliative care units. One family member per patient who died at a participating Veterans Affairs medical center between July 1, 2008, and December 31, 2009, was invited to participate. The telephone survey included 1 global rating item and 9 core items describing the patient's care in the last month of life.Results
Interviews were completed with family members for 5901 of 9546 patients. Of these, 1873 received usual care, 1549 received a palliative care consultation, and 2479 received care in a palliative care unit. After nonresponse weighting and propensity score adjustment, families of patients who received a palliative care consultation were more likely than those who received usual care to report that the patient's care in the last month of life had been “excellent” (adjusted proportions: 51% vs 46%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.02-1.55; P = .04). However, families of patients who received care in a palliative care unit were even more likely to report excellent care (adjusted proportions: 63% vs 53%; OR, 1.52; 95% CI, 1.25-1.85; P < .001).Conclusion
Care received in palliative care units may offer more improvements in care than those achieved with palliative care consultations.
Although most Americans prefer to die at home,1- 4 the majority die in inpatient settings. In 2005, approximately 29% of Medicare deaths in the United States occurred in an acute care hospital and 72% of those patients were hospitalized at least once in the last month of life.5 In addition, approximately 25% of patients die in nursing homes,6 a number that is likely to increase.7
Growing attention to end-of-life care has identified numerous problems with inpatient settings. For instance, many patients experience uncontrolled symptoms near the end of life.8- 10 In addition, communication regarding patients' illness and treatment is often insufficient,11- 15 and both patients and their families may not receive the emotional support they need.10,16- 18 Together, these problems contribute to families' negative assessments of end-of-life care.19- 23 To address these problems, hospitals and nursing homes have increasingly developed palliative care consultation teams.24- 30 According to a survey conducted in 2008,31 31% of all US hospitals now provide some form of palliative care.
There also has been growing interest in distinct palliative care units.32 These units rely on dedicated staff to provide tertiary palliative care33 and are analogous to dedicated intensive care units.32,34- 35 Palliative care units offer the potential to improve end-of-life care substantially. However, it is not known whether these units provide better care than a consultation team does. This question is important because dedicated palliative care units are resource intensive and require hospitals and nursing homes to make a substantial investment. Therefore, the goal of this study was to compare the effect of palliative care consultation teams with that of dedicated palliative care units on the quality of care in a national sample of hospitals and nursing homes in the Department of Veterans Affairs (VA) integrated health care system.
Archives of Internal Medicine 171(7):649-655. · 11.46 Impact Factor
