Exploring Nonresponse Bias in the Department of Veterans Affairs' Bereaved Family Survey

Background: Patients' and families' evaluations of health care, including palliative care, are widely used as performance measures. Survey scores may be affected by nonresponse bias, resulting in inaccurate performance evaluation. Objectives: Our aim was to examine nonresponse bias for the mailed version of the Department of Veterans Affairs (VA) Bereaved Family Survey Performance Measure (BFS-PM) and evaluate the effect of nonresponse bias on facilities' BFS-PM scores. Methods: A cross-sectional analysis of a national sample was conducted. The sample consisted of 20,540 veterans who died in one of 146 VA Medical Centers (VAMCs) between October 2012 and September 2013. Next of kin (NOK) were asked to complete and return the survey. The BFS-PM is defined as the proportion of NOK who rated overall care for the veteran during the last month of life as excellent. After creating a model to predict the likelihood of response based on patient and clinical characteristics, we applied inverse probability weights to examine their effect on facilities' scores. We also evaluated facility performance before and after weighting for nonresponse vis-a-vis varying benchmarks. Results: We received 8912 surveys (45% response rate). The mean change in facility BFS-PM scores after weighting was -2%, (range: -10% to+11%). The scores of 31% of facilities changed more than2%. The number of facilities meeting hypothetical benchmarks of 60%, 70%, and 80% also changed as a result of weighting for nonresponse. Conclusion: Our results underscore the importance of appropriately addressing nonresponse in the use of quality-of-care metrics based on Bereaved Family Survey (BFS) data.