title: Assessing the quality of care for dying patients from the bereaved relatives' perspective: further validation of "Evaluating care and health outcomes--for the dying".
abstract: BACKGROUND
  Evaluating Care and Health Outcomes-for the Dying (ECHO-D) is a post-bereavement questionnaire that assesses quality of care for the dying and is linked with the Liverpool Care Pathway for the Dying Patient (LCP).
  
  
  OBJECTIVE
  To further assess the validity and reliability of the ECHO-D, namely the construct validity, internal consistency, and test-retest reliability of key composite scales.
  
  
  METHODS
  Self-completion questionnaires were mailed to 778 next-of-kin of consecutive deceased patients who had died an "expected" cancer death in a hospice or acute tertiary hospital. For those willing to complete ECHO-D for a second time, another copy was sent a month later. Maximum likelihood factor analysis and Cronbach's alpha test were conducted for four key composite scales. Test-retest reliability was assessed using percentage agreement, Kappa statistic, and Spearman's correlation coefficient (ordinal data). Comparisons between hospice and hospital groups were conducted using one-way between-groups analysis of variance.
  
  
  RESULTS
  Following exclusions (n = 52), 255 of 726 next-of-kin agreed to participate (35.2% response rate). Maximum likelihood factor analysis showed a single factor for three of the scales, and all had good internal consistency (Cronbach's alpha >0.78). Barring two questions, all showed good or moderate stability over time. Overall, hospice participants reported the best quality of care, and hospital participants, where care was not supported by the LCP, reported the worst quality of care.
  
  
  CONCLUSIONS
  These findings support ECHO-D as a valid and reliable instrument to assess quality of care for the dying and assess the effectiveness of interventions such as the LCP.
authors.affiliation: Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, United Kingdom. Electronic address: catriona.mayland@liv.ac.uk.
authors.forename: Catriona R
authors.initials: CR
authors.lastname: Mayland
authors.affiliation: Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Evelyn M I
authors.initials: EM
authors.lastname: Williams
authors.affiliation: Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom.
authors.forename: Julia
authors.initials: J
authors.lastname: Addington-Hall
authors.affiliation: Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Trevor F
authors.initials: TF
authors.lastname: Cox
authors.affiliation: Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, United Kingdom.
authors.forename: John E
authors.initials: JE
authors.lastname: Ellershaw
mesh_terms: D000704:Analysis of Variance; D001601:Bereavement; D005163:Factor Analysis, Statistical; D005190:Family / Q000523:psychology*; D017051:Hospice Care; D006738:Hospices; D006801:Humans; D016013:Likelihood Functions; D009369:Neoplasms / Q000628:therapy; D011787:Quality of Health Care; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D013727:Terminal Care; D062606:Tertiary Care Centers; D013997:Time Factors
keywords: ECHO-D; Liverpool Care Pathway; Validation; dying; post-bereavement survey; proxy; quality of care