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1/17/2001

VA Home Care Helps Terminally Ill Veterans

Kate Traynor

A new study finds that a Department of Veterans Affairs (VA) home-based primary care (HBPC) program improves the well-being of patients who have been diagnosed with a terminal illness. However, veterans with less-dire prognoses generally fare as well in conventional care programs as they do under HBPC, which costs substantially more. 

VA’s HBPC program is a collaborative effort between family caregivers and an interdisciplinary team of health care professionals, including pharmacists, who treat chronically ill veterans at home. A previously published study found that one VA hospital’s HBPC program significantly improved the quality of life of veterans and their caregivers—and also reduced health care costs. The new study, which was described in the Dec. 13 Journal of the American Medical Association, examined HBPC programs at 16 VA hospitals, focusing on health-related quality of life, patient functional status, costs, and hospital readmissions.

According to the report, participation in the HBPC program boosted the quality-of-life scores of terminally ill veterans in six of eight health-related areas, including bodily pain and general health. HBPC also significantly improved at least six of eight health-related quality-of-life indicators for the caregivers.

Veterans without a terminal disease diagnosis reported greater satisfaction with the HBPC program, compared with those who were terminally ill, but showed no improvement in the eight health-related indicators. There was no significant difference in the "functional status" of veterans in the two treatment groups. Although 22 percent fewer HBPC program participants required hospitalization within the first six months than did usual-care patients, by 12 months the hospitalization rates for the two groups were similar.

The HBPC program cost $31,401 per patient per year, while conventional care cost $28,008.

The study was conducted between October 1994 and September 1998. It involved 1,966 veterans, 289 of whom had been diagnosed with a terminal illness. Patients were 70 years old on average and almost exclusively men. The average age of the caregiver was 62, and for about 80 percent of the veterans, this person was a female relative.

Veterans who qualified for the study had been diagnosed with a terminal illness or had two or more "activities of daily living impairments" such as difficulty bathing or dressing themselves. Also eligible were patients with chronic obstructive pulmonary disease or congestive heart failure. Patients with psychiatric disorders, spinal cord injuries, or a history of drug or alcohol abuse were excluded from the study.

The researchers stratified the veterans by study site, age, and diagnosis before randomly assigning them to a treatment group. Standardized rating systems were used to evaluate the functional status and quality-of-life factors affecting the veterans and their caregivers. Participants were rated at baseline and again at one, six, and 12 months.

A total of 981 veterans were randomly assigned to receive HBPC. These patients were cared for at home for "as long as needed, until maximum patient benefit was achieved, or until a different level of care was required." The usual-care group consisted of 985 veterans, each of whom could use any VA hospital service for which they qualified, as well as home care or hospice services not affiliated with VA.

Patients who received conventional care for treatment of a nonterminal illness reported less bodily pain than did similar veterans who received care through the HBPC program. Conventional care was rated significantly better than HBPC in only two other measures: the caregiver's rating of the functional status of a patient without terminal illness, and the objectively rated burden endurred by a caregiver in aiding a patient without a terminal disease.

Thirty-four percent of the veterans in each treatment group completed the one-year study and follow-up period. Another 34 percent of the patients in each treatment group died before the end of the study. About 25 percent of the patients refused to undergo follow-up testing or could not respond to the survey questions.

According to lead author Susan L. Hughes, D.S.W., the research team asked all participating sites to follow a specific model of care that she described as "less liberal" than that allowed by VA’s central HBPC office. A major component of Hughes’ model was the requirement that a physician be part of the HBPC team. Also important was the use of "step-down" units for stable readmitted patients and prior notification of the HBPC team when a patient was scheduled for readmission to the hospital.

Compliance with the main components of Hughes’ HBPC model was less than ideal among the VA hospitals that participated in the study. Ninety-four percent of the hospitals complied with two criteria: targeting HBPC care to high-risk patients, and designating a primary care manager within the HBPC team. Only 56 percent of the hospitals consistently notified HBPC staff of a patient's scheduled hospital readmission.

Hughes attributed the success of the earlier HBPC study to the hospital’s adherence to the stricter HBPC model.