At least 30% of veterans are over age 65 now, and 46% will be over 65 by 2030. These demographic trends mean that, like other health care systems, the VA will face substantial challenges of providing care to veterans near the end of life. Results from the FATE study will be useful in improving care for veterans at the end of life. A system-wide strategy to assess the quality of end-of-life care in the VA will make it possible to define and compare the quality of end-of-life care at each facility and to identify opportunities for improvement at the VISN level. In addition, facilities and VISNs will be able to monitor the effectiveness of efforts to improve care locally and nationally. Finally, a system-wide measurement strategy will help the VA to recognize those facilities that provide outstanding end-of-life care, so that successful processes and structures of care can be promptly identified and disseminated throughout the VA.
Our objective was to develop and validate the FATE (Family Assessment of Treatment at End-of-Life) Instrument for use as a system-wide tool to assess the quality of end-of-life care within the VA.
FATE included four research phases. In the first phase trained research assistants conducted qualitative interviews with approximately 60 family respondents familiar with the medical care of consecutive veterans who died in the care of one of 4 VA study facilities (Philadelphia, West Los Angeles, Lebanon, PA, and Louisville VAMCs). The interview questions were open-ended and designed to identify positive and negative aspects of care. Phase II consisted of cognitive interviews (n=30) at the above sites plus the Birmingham VAMC to evaluate the draft FATE survey instrument. (Phases III and IV were conducted at all 5 sites). In Phase III team members used psychometric testing to revise a draft of the instrument and in Phase IV we collected preliminary evidence of discriminant validity.
The FATE showed excellent psychometric characteristics, with good homogeneity (e.g. Cronbach's 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 vs. 52; rank sum test p<0.001), as did patients who were referred to hospice (67 vs. 49; rank sum test p<0.001).
Development of a system wide strategy to assess the quality of end-of-life care will allow the VA to make at least 3 essential improvements: First, a system-wide strategy to assess the quality of end-of-life care in the VA will make it possible to define and compare the quality of end-of-life care at each facility and to identify opportunities for improvement at the VISN level; Second, facilities and VISNs will be able to monitor the effectiveness of efforts to improve care locally and nationally; Third, a system-wide measurement strategy will help the VA to recognize those facilities that provide outstanding end-of-life care, so that successful processes and structures of can be promptly identified and disseminated throughout the VA.
A short version of the FATE (13 items) with similar response characteristics has been approved by the Office of Management and Budget for use nationwide as a quality measure. This version of the FATE is being rolled out on a VISN-by-VISN basis beginning with approximately 19 facilities in VISNs 3 and 4.
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- Finlay E, Shreve S, Casarett D. Nationwide veterans affairs quality measure for cancer: the family assessment of treatment at end of life. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2008 Aug 10; 26(23):3838-44.
- Casarett D, Pickard A, Bailey FA, Ritchie C, Furman C, Rosenfeld K, Shreve S, Chen Z, Shea JA. Do palliative consultations improve patient outcomes? Journal of the American Geriatrics Society. 2008 Apr 1; 56(4):593-9.
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- Jones D, Edes T, Shreve S, Casarett DJ. You won't know if you're improving unless you measure: recommendations for evaluating Hospice-Veteran Partnerships. Journal of pain and symptom management. 2006 Nov 1; 32(5):488-96.
- Casarett DJ, Clark CC, Fine MJ, Asch DA. CHERP Policy Brief: Improving end-of-life care for Veterans. 2009 Jul 30; 5(1).
- Casarett DJ. Is it time to redesign hospice: End-of-life care from the user's perspective. Paper presented at: American Geriatrics Society Annual Meeting; 2006 May 12; Chicago, IL.
- Casarett DJ, Pickard A, MacMoran HJ, Shreve S. Initial development of the FATE (Family Assessment of Treatment at End-of-life) as a VA-wide quality measure. Paper presented at: VA HSR&D National Meeting; 2005 Feb 17; Baltimore, MD.
Health Systems, Aging, Older Veterans' Health and Care
End-of-life, Quality assessment, Satisfaction (patient)