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FATE: Family Assessment of Treatment at End-of-life
David J Casarett MD MA
CHERP, Philadelphia VAMC
Division of Geriatrics University of Pennsylvania
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VA Mission: To Honor Veterans’ Preferences for Care at the End of Life
"VA must offer to "VA must offer to provide or provide or purchase purchase hospice & hospice & palliative care palliative care that VA that VA determines an determines an enrolled veteran enrolled veteran needs." needs." 38 CFR 17.36 38 CFR 17.36 and 17.38and 17.38
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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
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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
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Data availability sets the VA apart: Potential for nationwide quality
measurementStructures 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?
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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
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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)
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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
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Sites (Phase I)
PhiladelphiaBirminghamWest Los AngelesLouisvilleLebanon
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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)
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Reporting
Anonymous (self-identified only)Domain scores and rankingsFuture: case-mix adjustedwww.caringforveterans.org
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Site-specific feedback:www.caringforveterans.org
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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?
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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.
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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.
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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
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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)
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Preliminary results: summary
Inpatient PC improves careHome hospice probably improves careThere is substantial variation among hospice
programsInpatient PC may be as good as home
hospice care
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Next steps
Approval for QI useApproval as a national quality measureRollout nationally
» Central administration?» Central data collection» Routine reporting and integration into VISN quality
initiatives
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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
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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?