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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: 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: The Veterans Affairs (VA) health care system has created a national initiative to measure quality of care at the end of life. This article describes the first phase of this national initiative, the Family Assessment of Treatment at End of Life (FATE), in evaluating the quality of end-of-life care for veterans dying with cancer. In the initial phase, next of kin of patients from five VA Medical Centers were contacted 6 weeks after patients' deaths and invited to participate in a telephone interview, and surrogates for 262 cancer patients completed FATE interviews. Decedents were 98% male with an average age of 72 years. There was substantial variation among sites. Higher FATE scores, consistent with family reports of higher satisfaction with care, were associated with palliative care consultation and hospice referral and having a Do Not Resuscitate order at the time of death, whereas an intensive care unit death was associated with lower scores. Early experience with FATE suggests that it will be a helpful tool to characterize end-of-life cancer care and to identify targets for quality improvement.
Journal of Clinical Oncology 09/2008; 26(23):3838-44. · 18.37 Impact Factor
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ABSTRACT: To determine whether inpatient palliative consultation services improve outcomes of care.
Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life.
Five VA Medical Centers or their affiliated nursing homes and outpatient clinics.
Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey.
The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items).
Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62-66) versus 54 (95% CI=51-56; P<.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (beta=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support.
Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.
Journal of the American Geriatrics Society 05/2008; 56(4):593-9. · 3.74 Impact Factor
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ABSTRACT: To identify aspects of end-of-life care in the U.S. Department of Veterans Affairs (VA) health care system that are not assessed by existing survey instruments and to identify issues that may be unique to veterans, telephone interviews using open-ended questions were conducted with family members of veterans who had received care from a VA facility in the last month of life. Responses were compared to validated end-of-life care assessment instruments in common use. The study took place in four VA medical centers and one family member per patient was invited to participate, selected from medical records using predefined eligibility criteria. These family members were asked to describe positive and negative aspects of the care the veteran received in the last month of life. Interview questions elicited perceptions of care both at VA sites and at non-VA sites. Family reports were coded and compared with items in five existing prospective and retrospective instruments that assess the quality of care that patients receive near the end of life. Interviews were completed with 66 family members and revealed 384 codes describing both positive and negative aspects of care during the last month of life. Almost half of these codes were not represented in any of the five reference instruments (n=174; 45%). These codes, some of which are unique to the veteran population, were grouped into eight categories: information about VA benefits (n=36; 55%), inpatient care (n=36; 55%), access to care (n=33; 50%), transitions in care (n=32; 48%), care that the veteran received at the time of death (n=31; 47%), home care (n=26; 40%), health care facilities (n=12; 18%), and mistakes and complications (n=18; 27%). Although most of the reference instruments assessed some aspect of these categories, they did not fully capture the experiences described by our respondents. These data suggest that many aspects of veterans' end-of-life care that are important to their families are not assessed by existing survey instruments. VA efforts to evaluate end-of-life care for veterans should not only measure common aspects of care (e.g., pain management), but also examine performance in areas that are more specific to the veteran population.
Journal of Pain and Symptom Management 03/2008; 35(2):115-25. · 2.50 Impact Factor
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ABSTRACT: The pursuit of a "good death" remains out of reach for many despite numerous piecemeal solutions to address the growing need for access to quality care at the end of life. In 2002, U.S. veteran deaths were at an all-time high, few Department of Veterans Affairs (VA) hospitals had inpatient palliative care services, and there was no reliable approach to meet home hospice needs. The VA embarked on a course of major change to improve veterans' care at the end of life. A coordinated plan to increase access to hospice and palliative care services was established, addressing policy development, program and staff development, collaboration with community hospices, outcomes measurement, and proving value to the organization. To determine progress and monitor resource allocation, workload and outcome measures were established in all settings. Within 3 years, the number of veterans receiving VA-paid home hospice had tripled, all VA hospitals had a palliative care team, 42% of all veterans who died as VA inpatients received a palliative care consultation, and a nationwide network of VA partnerships with community hospice agencies was established. Through a multifaceted strategic plan and a mission of honoring veterans' preferences for care at the end of life, the VA has made rapid progress in improved access to palliative care services for inpatients and outpatients. The VA's experience serves as a powerful example of the magnitude of change possible in a complex health system and a model for improving access and quality of palliative care services in other health systems.
Journal of the American Geriatrics Society 11/2007; 55(10):1645-9. · 3.74 Impact Factor
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ABSTRACT: Growing evidence indicates that there are abundant opportunities to improve the care that patients receive near the end of life. Hospice care has been associated with improvements in these and other outcomes, but hospice is underused by most patient populations. Therefore, the Department of Veterans Affairs (VA) has made hospice access a priority in its plan to improve end-of-life care for all veterans. In addition to committing funding for hospice care, the VA has also established a national network of Hospice-Veteran Partnerships (HVPs) whose goal is to improve access to hospice for veterans. This article describes the results of a nationwide consensus project to develop measures of the success of HVPs and recommends key measures that should be used to track improvements and to identify opportunities for highly successful collaborative strategies.
Journal of Pain and Symptom Management 12/2006; 32(5):488-96. · 2.50 Impact Factor
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ABSTRACT: To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system.
Nationwide telephone survey.
Five VA medical centers.
Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate.
The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patient's death (3 items).
Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001).
The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.
Journal of Palliative Medicine 11(1):68-75. · 1.85 Impact Factor
