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 "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

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

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?

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)

PhiladelphiaBirminghamWest Los AngelesLouisvilleLebanon

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)

Reporting

Anonymous (self-identified only)Domain scores and rankingsFuture: case-mix adjustedwww.caringforveterans.org

Site-specific feedback:www.caringforveterans.org

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 careHome hospice probably improves careThere is substantial variation among hospice

programsInpatient PC may be as good as home

hospice care

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

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?