FATE: Family Assessment of Treatment at End-of-life

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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 provide or purchase hospice
  palliative care that VA determines an enrolled
  veteran needs."
• 38 CFR 17.36 and 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 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?

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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

VA is responsible
VA is accountable
Only the VA is accountable
http//www.va.gov/vetdata/demographics/index.htm
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Sites (Phase I)

• Philadelphia
• Birmingham
• West Los Angeles
• Louisville
• Lebanon

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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 rankings
• Future case-mix adjusted
• www.caringforveterans.org

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Site-specific feedbackwww.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, n309)

• Yes 86 vs. 64 (plt0.001)
• 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, n143)

• 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 (P0.010)
• 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)
• (P0.014)

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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

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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

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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?