Associations between Veterans Health Administration nursing home star ratings and quality end of life care

Abstract: Outcomes: 1. Describe gaps in five-star quality rating system in measuring nursing home end-of-life care quality. 2. Identify two areas for improvement and/or active monitoring in the end-of-life care experience using the five-star quality rating system. Key message: In a cohort of 4,637 Veterans who died in a Department of Veterans Affairs nursing home there was no significant relationship between nursing home star ratings and bereaved family evaluations of end-of-life care. Findings suggest that nursing homes star rating systems do not measure the quality of end-of-life care. Importance: In Veterans Health Administration (VA)-operated nursing homes, known as Community Living Centers (CLCs), approximately one-third of residents die during their stay. Thus, commonly used five-star quality rating systems, such VA CLC Compare, should reflect quality of end-of-life (EOL) care; however, the relationship between CLC Star Ratings and EOL care quality is unknown. Objective(s): To examine associations between VA CLC Compare star ratings and quality of EOL care as measured by VA's Bereaved Family Survey (BFS). Scientific methods utilized: This retrospective observational study examined all Veterans who died in a CLC from October 2018 - September 2019 whose next-of-kin completed a BFS. CLC Star Ratings were based on performance in three domains: On-site Survey, Staffing, and Quality Measures. Primary outcome: BFS global rating item. Secondary outcomes: BFS factors of Respectful Care and Communication, Emotional and Spiritual Support, and Death Benefits; and individual BFS items related to management of pain and post-traumatic stress symptoms. Results: Of the 4,637 Veterans in the sample, the mean age was 79 years; 4507 (97%) were male; and 3536 (76%) were non-Hispanic white. Differences in the BFS global rating at the facility-level (i.e., the BFS Performance Measure) by CLC star rating were small to none and not statistically significant. There was no significant relationship between a higher CLC Overall Star Rating and odds of an “excellent” BFS global rating (adjusted odds ratio 1.02; 95% CI 0.94-1.11; p=0.60). Similarly, no statistically significant relationships were observed between a higher CLC Overall Star Rating and scores on the BFS factors and symptom management items. Conclusion(s): Our findings suggest that the current CLC star rating system is not sufficient to assess the quality of EOL care. Impact: Our findings underscore the need for BFS scores or a comparative EOL quality of care measure to be integrated into five-star quality rating systems.

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