Presentation on theme: "FATE: Family Assessment of Treatment at End-of-life David J Casarett MD MA CHERP, Philadelphia VAMC Division of Geriatrics University of Pennsylvania."— Presentation transcript:
FATE: Family Assessment of Treatment at End-of-life David J Casarett MD MA CHERP, Philadelphia VAMC Division of Geriatrics University of Pennsylvania
VA Mission: To Honor Veterans’ Preferences for Care at the End of Life "VA must offer to provide or purchase hospice & palliative care that VA determines an enrolled veteran needs." 38 CFR 17.36 and 17.38
How well are we doing? Data are needed: »To identify problems »To distinguish high- vs. low-performing facilities »To guide improvement efforts »To shape policy related to: Funding Workforce Health care systems organization
Quality measurement opportunities in VHA Opportunity to translate data into policy Opportunity for a public health approach/population -based Data-rich health care system and Electronic Medical Record
Data availability sets the VA apart: Potential for nationwide quality measurement Structures of care »Consult services »HVPs »Inpatient units Processes of care »Consults »Referrals to hospice Outcomes (provide answers to key policy- relevant questions) »Do palliative care consults improve care? »Does home hospice improve care?
Background HSRD-funded instrument development project Multisite »5 sites in initial phase (current) »15 sites in feasibility test Preliminary version approved by Office of Management and Budget as a quality tool (10/06) Planned for review as a Type III (mandatory) Directors performance measure
Approach Afterdeath telephone interview of families »Enrolled veterans who had at least one healthcare contact with the VA in the last month of life »Inpatient, outpatient, and NHCU deaths Eligibility »National death bulletin notifications »Chart review »Letter to families »Telephone call (approximately 2 months after death)
Epidemiology of the veteran population (2005) ~24,000,000 living veterans »~687,000 projected veteran deaths (2005- 2006) ~100,000 enrolled deaths ~29,000 inpatient deaths http://www.va.gov/vetdata/demographics/index.htm VA is responsible Only the VA is accountable VA is accountable
Sites (Phase I) Philadelphia Birmingham West Los Angeles Louisville Lebanon
Domains Well-being and dignity (5 items) Communication (4 items) Care consistent with preferences (2 items) Symptom management (4 items) Care around the time of death (5 items) Emotional/spiritual support (4 items) VA services (3 items) VA death benefits (3 items) Admitted to facility of choice (1 item)
Value to the VA: Examples of 3 policy-relevant questions Do palliative care consults improve care? Does home hospice improve care? Is home hospice better than inpatient palliative care?
Value to the VA: Do PC consults improve care? (FATE score, n=309) Yes: 86% vs. 64% (p<0.001)* *Adjusted for age ethnicity, income, diagnosis (cancer vs. non-cancer), and site.
Value to the VA: Does hospice improve care for deaths at home? (FATE score, n=143) Maybe: 89% vs. 85% (not significant)* BUT: Significant interaction by site (e.g. hospices in some cities have a greater effect than in others). *Adjusted for age, ethnicity, income, diagnosis (cancer vs. non-cancer) and LOS.
All hospices are not equal Died at home with hospice: »Range across sites (means): 43-78 (P=0.010) »Small variation in VA service scores »Larger variation in VA death benefits »Large variation in communication, care around the time of death, and symptoms
No place like home? Died at home with hospice: »FATE score mean 67 (IQ range 45-76) Died in a VA hospital with palliative care: »FATE score mean 76 (IQ range 64-82) (P=0.014)
Preliminary results: summary Inpatient PC improves care Home hospice probably improves care There is substantial variation among hospice programs Inpatient PC may be as good as home hospice care
Next steps Approval for QI use Approval as a national quality measure Rollout nationally »Central administration? »Central data collection »Routine reporting and integration into VISN quality initiatives
Collaborators Support FATE collaborators and supporters: »Ken Rosenfeld MD »Christine Ritchie MD MPH »Scott Shreve MD »Christian Furman MD »Amos Bailey MD »Tom Edes MD »Diane Jones MSW VA RCD 00008-01 and ARCDA VA HSRD IIR 03-128-2 VA CPP #217 VA CSP #476 Center for Health Equity Research and Promotion R01 CA109540-01 Paul Beeson Physician Scholars Award NIH K01 AI 01739-01 Hartford Foundation VistaCare Foundation Commonwealth Fund Greenwall Foundation
Questions: How to integrate with FEHC? How could these data be useful to hospices? How could hospice partner with VA facilities to help them improve their FATE scores?