Patient satisfaction of female and male users of Veterans Health Administration services

"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration

OBJECTIVE

To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience.

DATA SOURCES AND STUDY SETTING

From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare.

STUDY DESIGN

Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached.

DATA COLLECTION/EXTRACTION METHODS

For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis.

PRINCIPAL FINDINGS

We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide.

CONCLUSIONS

Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

Pharmacy services and psychiatric patient satisfaction among community-based health insurance users in Ethiopia

Background

The development of community-based health insurance (CBHI) was driven by the need to provide economic protection for the poor against unexpected healthcare expenses. This can lead to increased patient satisfaction with their overall care. Maintaining high levels of client satisfaction with pharmacy services is crucial for effectively treating patients with psychiatric disorders. Therefore, the purpose of this study was to assess the impact of pharmacy services on psychiatry patient satisfaction among users of CBHI in the psychiatric setting.

Methods

A multicenter cross-sectional study was conducted at the psychiatric clinics with a systematic random sampling technique between December 2023 and May 2024. A structured interview questionnaire was used to gather data. Both bivariate and multivariate analysis were employed. In multivariate analysis, variables having a p-value of < 0.05 were deemed statistically significant.

Result

A total of 420 participants were enrolled with a response rate of 99.5%. Overall, 261 (62.1%) of the patients reported being satisfied with the pharmacy service. However, a significant number of patients expressed dissatisfaction with certain aspects of the service, such as pharmacist counseling on medication side effects (43.1%), medication interactions (36.9%), and labeling and dispensing of medicines (42.4%). According to the study, living in an urban area [AOR = 2.0; 95% CI (1.25, 3.2); P = 0.04], being between the ages of 18-35 and 36-44 [AOR = 2.7, 95% CI (1.38, 5.3), p = 0.04] and [AOR = 3.3, 95% CI (1.6, 5.7), p = 0.001] respectively. First and second visits to the institution [AOR = 2.2; 95% CI (1.15, 4.4); P = 0.01] and [AOR = 1.9; 95% CI (1.13, 3.3); P = 0.01] respectively. Having two psychiatric disorders [AOR = 1.8, 95% CI (1.07, 3.07), p = 0.02] and all drug availability [AOR = 1.5, 95% CI (1.3, 3.43), p = 0.02], were positively associated with psychiatry patient pharmacy service satisfaction.

Conclusion

In this study, the users of CBHI psychiatric patients were generally satisfied with the pharmacy service. Additionally, being urban residency age (18-44 years), first and second visits to the institution, having two psychiatric disorders and all drug availability were found to have a significant impact on psychiatric patient pharmacy services satisfaction.

Differences by Sexual Orientation in Patient-Centered Care Outcomes for Veterans Utilizing Primary Care Services at the Veterans Health Administration

Purpose: This study examined the differences by sexual orientation in patient-centered care outcomes (including health care experiences and health-related screening) of veterans utilizing Veterans Health Administration (VHA) primary care. Methods: VHA's adapted version of the Consumer Assessment of Healthcare Providers and Systems was used to compare the health care experience of primary care services among sexual minority (SM) and heterosexual veterans. Health care experience measures were dichotomized to "always" versus "less" and stratified by SM status. Health-related screening measures were dichotomous. Survey data were weighted using provided sample weights. Descriptive statistics were performed on sociodemographic characteristics. Logistic regression coefficients were represented as adjusted odds ratios (aORs). A total of 66,348 veterans were included in the analytic sample, of which 2.9% (n = 1,935) identified as SM. Sexual orientation was ascertained by self-report measures by veterans. Results: SM veterans were significantly younger (56.95 years vs. 63.43 years, p < 0.001), were less likely to report that their provider showed respect for what they had to say (aOR: 0.76; 95% confidence interval [CI]: 0.61-0.95), that they were asked about difficulties taking care of their health (aOR: 0.81; 95% CI: 0.67-0.96), and their provider listened carefully to them (aOR: 0.71; 95% CI: 0.57-0.87) compared to heterosexual veterans. Conclusion: Health care experiences differed between SM and heterosexual veterans who sought VHA primary care, suggesting the need to increase provider trainings, which may improve cultural competency and promote a more welcoming and inclusive environment.

Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex

Importance

Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups.

Objective

To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex.

Design, Setting, and Participants

This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022.

Main Outcomes and Measures

The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group.

Results

Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect.

Conclusions and Relevance

In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Long COVID coping and recovery (LCCR): Developing a novel recovery-oriented treatment for veterans with long COVID

Background

Long COVID has affected 13.5% of Veterans Affairs (VA) Healthcare System users during the first pandemic year. With 700,000+ United States Veterans diagnosed with COVID-19, addressing the impact of Long COVID on this population is crucial. Since empirically-based mental health interventions for Long COVID are lacking, a vital need exists for a tailored recovery-oriented intervention for this population. This study intends to assess the feasibility and acceptability of a novel recovery-oriented intervention, Long COVID Coping and Recovery (LCCR), for Veterans with Long COVID, aiming to support symptom management and quality of life. LCCR is an adaptation of Continuous Identity Cognitive Therapy (CI-CT), a suicide recovery-oriented treatment for Veterans.

Methods

In a two-year open-label pilot, three single-arm treatment trials will be conducted with 18 Veterans suffering from Long COVID. Each trial includes 16 weekly 60-min sessions delivered via VA Video Connect (VVC) and/or VA WebEx. Primary objectives include optimizing LCCR for Veterans with Long COVID and assessing the acceptability and feasibility of the intervention, using attendance and retention rates, drop-out statistics, and client satisfaction levels. Additionally, potential benefits of LCCR will be explored by evaluating alterations in quality of life, resilience, mental health status (anxiety, depression, suicide risk/behavior), and personal identity. The protocol has been tailored based on Veterans' needs assessment interviews and stakeholder feedback.

Conclusion

If the LCCR intervention proves feasible and acceptable, a manualized version will be created and a randomized controlled trial planned to examine its efficacy in the broader Veteran population.

Patient Satisfaction With Dental Services

Patient satisfaction is an integral aspect of healthcare quality assessment, and it plays a crucial role in evaluating the effectiveness of healthcare services. This systematic review investigates patient satisfaction with dental services provided by public dental hospitals in rural and remote areas of Saudi Arabia. The study conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards. It involved a comprehensive search across multiple databases, including Medline, Cochrane, Embase, and CINAHL, with tailored search strategies for each database using MeSH terms and keywords. To ensure inclusivity, the search covered publications in both English and Arabic and included Google Scholar for gray literature. Inclusion criteria focused on empirical studies conducted in rural and remote public hospitals in Saudi Arabia, published between 2013 and January 2023, assessing patient satisfaction in oral or dental care for adult patients. Data screening and extraction followed a rigorous two-step process, and a narrative synthesis was used to analyze and summarize the findings. The findings reveal a complex landscape of patient satisfaction in these settings, with varying levels of contentment reported. While more than 50% of patients expressed satisfaction with the quality of dental care, significant challenges related to accessibility were evident. Patients residing in remote and rural areas often had to travel long distances to access dental clinics, resulting in dissatisfaction. Demographic factors, particularly education and age, were identified as significant influencers of patient satisfaction, with more educated individuals tending to be less satisfied. This study emphasizes the importance of continuous monitoring of patient satisfaction to enhance service delivery, particularly in public dental clinics serving remote and rural areas. Addressing issues related to access, availability, clinical quality, and effective communication is vital for improving patient satisfaction in these healthcare settings. The study concludes with recommendations for policymakers, including the development of quality assurance policies, cost mitigation strategies, and targeted interventions to address demographic disparities and enhance patient satisfaction with dental care services.

Barriers and facilitators to mental healthcare for women veterans: a scoping review

BACKGROUND

Traditionally, veteran research and support have centred on the requirements of a predominantly male population. However, as female participation in the Armed Forces increases and their roles diversify, consideration of women's unique mental health needs is imperative. Women veterans are at greater risk of post-service mental health challenges than their male counterparts, and female mental health outcomes have deteriorated in recent years.

AIMS

To determine the provenance of these outcomes, a scoping review considering both barriers and facilitators to female veteran participation in mental health services was conducted.

METHODS

A review was carried out following the 2020 Joanna Briggs Institute Scoping Review framework. Twenty-four papers were identified, with all but one originating from the US.

RESULTS

This research indicated that whilst women experience barriers common to male veterans (e.g. help-seeking stigma), they also experience unique gender-specific barriers to accessing mental healthcare services (e.g. lack of gender-sensitive treatment options, feeling uncomfortable) and such barriers result in under-utilization of services.

CONCLUSIONS

Literature indicates that consideration and mitigation of these barriers might improve access and health outcomes for women veterans. Further research is required outside the US to understand the barriers to mental healthcare experienced by women veterans internationally.

Feasibility and acceptability of continuous identity cognitive therapy as a recovery-oriented suicide treatment for Veterans: A study protocol

Background

Suicide is a leading cause of death among Veterans, with rates significantly higher than the general population. To address this issue, it is crucial to develop and implement more effective treatments for Veterans with suicidal thoughts and/or behaviors, particularly those in the post-acute suicidal episode (PASE) stage. The present study aims to establish the feasibility and acceptability of a novel, recovery-oriented treatment called Continuous Identity Cognitive Therapy (CI-CT) for PASE Veterans.

Methods

This 3-year open-label pilot study will include three one-arm trials and a pilot randomized controlled trial (RCT). A total of 57 Veterans with a history of an acute suicidal episode within the previous year will be recruited. Primary outcome measures will include changes in personal recovery, suicidal thoughts, and behaviors. Secondary outcomes will include changes in self-identity, life satisfaction, and hopefulness. Feasibility and acceptability will be assessed through attendance and retention rates, drop-out rates, and client satisfaction.

Conclusion

This study aims to develop and evaluate the feasibility and acceptability of a novel recovery-oriented intervention for Veterans experiencing PASE. If the intervention is found to be feasible and acceptable, a manualized version will be finalized and a large-scale multi-site RCT will be designed to assess its clinical efficacy on a broader Veteran population. The results of this trial will aid in the development of effective treatment and provide valuable insights into the preliminary feasibility, acceptability, and effectiveness of this approach in reducing suicidal thoughts and behaviors and promoting recovery and rehabilitation in this population.

Patient Satisfaction with Care Providers During the COVID-19 Pandemic: An Analysis of Consumer Assessment of Healthcare Providers and Systems Survey Scores for In-Person and Telehealth Encounters at an Academic Medical Center

Background: Previous research has demonstrated high patient satisfaction with telehealth encounters. The objective of this study was to compare patient satisfaction scores regarding their physician using the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys between in-person and telehealth outpatient encounters during the pandemic at a large academic health center. Methods: We analyzed CAHPS patient satisfaction survey data within the UC Davis Health system between August 2020 and February 2022. The questions analyzed pertained to patients' satisfaction with their care provider; whether they felt included in discussions, would recommend their physician, received clear explanations, and that their concerns were heard. Using logistic regression models adjusting for confounders, we compared CAHPS care provider top box scores-a score of 4 or 5 on the 5-point scale-for 5 survey items. Results: Survey results from 76,687 (84.2%) in-person encounters and 14,404 (15.8%) telehealth encounters were evaluated. The odds of a telehealth patient giving a top box score for whether they would recommend their care provider to others were 0.97 those of an in-person patient (95% confidence interval [0.87-1.06]; p = 0.494). Similarly, there was no significant difference in odds of giving a top box score between telehealth and in-person patients for the other four questions analyzed. Discussion: Our findings indicate that patient experience and care provider rankings for in-person care and telehealth care are comparable across a variety of specialties and conditions at a large academic health center. Future studies should investigate patient satisfaction with in-person and telehealth encounters by diagnosis and specialty.

High-Risk Patient Experiences Associated With an Intensive Primary Care Management Program in the Veterans Health Administration

Intensive management programs may improve health care experiences among high-risk and complex patients. We assessed patient experience among (1) prior enrollees (n = 59) of an intensive management program (2014-2018); (2) nonenrollees (n = 356) at program sites; and (3) nonprogram site patients (n = 728), using a patient survey based on the Consumer Assessment of Healthcare Providers and Systems in 2019. Outcomes included patient ratings of patient-centered care; overall health care experience; and satisfaction with their usual outpatient care provider. In multivariate models, enrollees were more satisfied with their current provider versus nonenrollees within program sites (adjusted odds ratio 2.36; 95% confidence interval 1.15-4.85).

'Treat everyone like they're a man': Stakeholder perspectives on the provision of health and social care support for female veterans in the UK

International research suggests that female veterans may experience gender-specific barriers to accessing veteran-specific care. This is the first UK study to report an exploratory qualitative investigation of the provision of health and social care support for female veterans and whether this support meets their needs. The research team carried out 13 virtual semi-structured interviews between October and November 2020, with representatives from statutory and third sector organisations that provide support to UK female veterans. Ethical approval was obtained from the Anglia Ruskin University School of Education and Social Care Research Ethics Committee. The authors identified four overarching themes and nine sub-themes in a thematic analysis following the framework outlined by Braun and Clarke (2006). The findings of this study suggest that practitioners from statutory and third sector organisations perceive the UK veteran support sector as male-dominated and male-targeted, with a lack of consideration for female veterans' needs. Participants reported a lack of engagement with veteran-specific services by female veterans and suggested that women either do not identify with the 'veteran' label or do not feel comfortable accessing male-dominated veteran-specific services. The need for specific services for female veterans split participant opinion, with most of those who were female veterans themselves highlighting the importance of 'safe spaces' for women, particularly those who had experienced gender-based violence during military service. Others felt that the veteran support sector currently lacked evidence of women's unique support needs, and an examination of current provision was required. The authors recommend a thorough assessment of UK female veterans' health and social care needs, alongside development of training and guidance for health and social care professionals, to ensure that veteran services are adequately developed, tailored and targeted with women's needs in mind.

Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017

BACKGROUND

Home telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade.

OBJECTIVE

To describe trends in use of VHA's HT program from 2010 through 2017 and correlates of length of enrollment in HT services.

DESIGN

Retrospective observational cohort study.

PARTICIPANTS

Patients enrolled in HT between January 1, 2010 and December 31, 2017.

MAIN MEASURES

We described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment.

KEY RESULTS

The total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index.

CONCLUSIONS

Across 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.

Women Veterans' Attrition from the VA Health Care System

PURPOSE

Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care.

METHODS

A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.

RESULTS

Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.

CONCLUSIONS

Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.

Sex Differences in the Care Experiences of Patients Hospitalized Due to Ischemic Heart Disease in Alberta, Canada

BACKGROUND

Women with heart disease experience disparities in the diagnosis, treatment, and management of their condition. However, it is unknown whether these sex differences exist with respect to in-hospital patient experience. We examined the comprehensive experience of patients hospitalized due to ischemic heart disease (IHD) across Alberta, Canada, according to sex.

METHODS

Patients completed a modified version of the Canadian Patient Experiences Survey-Inpatient Care (CPES-IC) within 6 weeks of discharge. We examined 37 questions, including 33 regarding specific care processes and 4 global rating scales. Survey responses were reported as raw "top-box" percentages, that is, the most-positive answer choice to each question. Odds and corresponding 95% confidence intervals of women reporting a top-box response were then calculated for each question, while controlling for demographic and clinical factors.

RESULTS

From April 2014 to March 2020, a total of 5795 surveys (1612 women, 4183 men) were completed. Taking the survey margin of error into account, women had lower top-box percentages on 26 of 37 questions. Similar results were obtained for the adjusted odds of reporting a top-box response. Women did not have a higher percentage of top-box responses on any of the questions studied.

CONCLUSIONS

This study is a Canadian first, which stratified the experiences of hospitalized patients living with ischemic heart disease according to sex. Our results highlighted important sex differences. Future research to understand the mechanisms associated with these observed sex differences in patient-reported experiences is warranted.

Gender differences in barriers to mental healthcare for UK military veterans: a preliminary investigation

INTRODUCTION

Limited UK research focuses on female military veterans' gender-related experiences and issues when accessing civilian mental healthcare support. This study sought to illuminate a preliminary understanding of any gender differences in barriers that may discourage them accessing mental healthcare support.

METHODS

A total of 100 participants completed an open online survey of UK triservice veterans who identified as having experienced postmilitary mental health problems. They completed a 30-item Barriers to Access to Care Evaluation scale and were asked to elaborate using free-text questions. Resulting quantitative data were analysed for gender-related differences, while the qualitative text was thematically explored.

RESULTS

While stigma, previous poor experience of mental healthcare and a lack of trust in civilian providers were found to act as barriers to postmilitary support for both men and women, significantly more women reported that their gender had also impacted on their intention to seek help. Women also commented on the impact of gender-related discrimination during service on their help-seeking experiences.

CONCLUSIONS

While efforts are being made by the UK Ministry of Defence to reduce barriers to mental healthcare for those still serving in the Armed Forces, it has been more difficult to provide a similar level of support to the veteran population. With little veteran research focusing on the specific experiences of women, this study suggests that female veterans encounter specific access barriers and issues related to their gender. Further research is therefore needed to ensure these findings are addressed.

Client Satisfaction with Community Health Workers in HIV Care Teams

Community health workers (CHWs) integrated in human immunodeficiency virus (HIV) care teams undertake a variety of tasks to help patients navigate health care, develop care plans, and address social needs. Given the broad role of CHWs in HIV care, we sought to understand which client attributes are associated with various dimensions of CHW satisfaction using a sample of 204 people with HIV (PWH) from various geographic regions across the United States. Multivariable linear regressions were used to determine which client attributes were associated with complete satisfaction with CHWs using 10 validated measures. The mean age of participants was 40.6 years old (SD = 12.8) and over 70% were Black or African American. Adjusted models reveal clients who were female, have marginal health literacy, or have a substance use disorder diagnosis were more likely to not be completely satisfied across multiple dimensions (p ≤ .05). Conversely, being housed and having a mental health diagnosis were associated with being more likely to be completely satisfied (p ≤ .04). Clients' sociodemographic characteristics and health conditions may be indicative of unique needs, leading to differing expectations of CHWs. CHW training modalities should consider the complex interplay of care needs based upon different client backgrounds and experiences among PWH. Addressing unique needs resulting from social determinants of health and that arise from conditions co-occurring with HIV, such as substance use disorders, should be incorporated into CHW service delivery.

Measuring the Patient Experience of Mental Health Care: A Systematic and Critical Review of Patient-Reported Experience Measures

BACKGROUND

There is growing concern about measuring patient experience with mental health care. There are currently numerous patient-reported experience measures (PREMs) available for mental health care, but there is little guidance for selecting the most suitable instruments. The objective of this systematic review was to provide an overview of the psychometric properties and the content of available PREMs.

METHODS

A comprehensive review following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines was conducted using the MEDLINE database with no date restrictions. The content of PREMs was analyzed using an inductive qualitative approach, and the methodological quality was assessed according to Pesudovs quality criteria.

RESULTS

A total of 86 articles examining 75 PREMs and totaling 1932 items were included. Only four PREMs used statistical methods from item response theory (IRT). The 1932 items covered seven key mental health care domains: interpersonal relationships (22.6%), followed by respect and dignity (19.3%), access and care coordination (14.9%), drug therapy (14.1%), information (9.6%), psychological care (6.8%) and care environment (6.1%). Additionally, a few items focused on patient satisfaction (6.7%) rather than patient experience. No instrument covered the latent trait continuum of patient experience, as defined by the inductive qualitative approach, and the psychometric properties of the instruments were heterogeneous.

CONCLUSION

This work is a critical step in the creation of an item library to measure mental health care patient-reported experience that will be used in France to develop, validate, and standardize item banks and computerized adaptive testing (CAT) based on IRT. It will also provide internationally replicable measures that will allow direct comparisons of mental health care systems.

TRIAL REGISTRATION

NCT02491866.

Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care

Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.

Greater patient-centered medical home implementation was associated with lower attrition from VHA primary care

BACKGROUND

Patient-centered medical home models such as the Veterans Health Administration (VHA) Patient Aligned Care Team (PACT) model aim to improve primary care through accessible, comprehensive, continuous team-based care. Practices that adhere to patient-centered medical home principles have been found to exhibit higher patient satisfaction, possibly leading to higher retention of patients longitudinally and reducing attrition from care. We examined whether greater PACT implementation was related to lower attrition from VHA primary care.

METHODS

A national cohort of 1.5 million nonelderly patients with chronic conditions and using VHA primary care in the baseline year (fiscal year 2015) was identified. Attrition was measured as not receiving primary care over two subsequent years. PACT implementation in 863 VHA primary care practices was measured by the PACT Implementation Progress Index (Pi2) across 8 domains.

RESULTS

Overall, the attrition rate was 4.4%. Predicted attrition was highest for patients treated in practices with the lowest PACT implementation scores (4.8%) compared to 4.0% among patients in practices with the highest PACT implementation scores (difference = -0.8 (95% CI: -1.3, -0.2)). Better performance on most PACT domains was significantly associated with lower attrition.

CONCLUSIONS

Primary care practices that facilitate easier access to providers as well as provide more seamless care coordination, better communication with providers, and support for self-management appear to positively affect patients' decisions to stay in VHA care.

IMPLICATIONS

Provision of accessible, comprehensive, team-based primary care, as measured in this study, is likely to be a determinant of patient retention in VHA care.

LEVEL OF EVIDENCE

3.

Components of the Patient-Centered Medical Home Associated with Perceived Access to Primary Care

BACKGROUND

Following implementation of the patient-centered medical home (PCMH) within the Department of Veterans Affairs (VA), access to primary care improved. However, understanding of how this occurred is lacking.

OBJECTIVE

To examine the association between organizational aspects of the PCMH model and access-related initiatives with patient perception of access to urgent, same-day, and routine care within the VA.

DESIGN

Cross-sectional PARTICIPANTS: Veterans who responded to the annual Survey of Healthcare Experiences of Patients in 2016 (N = 241,122 patients) and primary staff who responded to VA National Primary Care Provider and Staff Survey (N = 4815 staff).

MAIN MEASURES

Three outcomes of perception of access: percentage of patients responding in the highest category for same-day care (waiting ≤ 1 day), urgent care (always receiving care when needed), and routine care (always receiving checkups when desired). Predictors were staff-level report of access-related initiatives and organizational factors in the clinic. We used generalized estimating equations to model associations, adjusting for characteristics of patients and their respective clinics.

KEY RESULTS

Access was significantly better in clinics where staff reviewed performance reports (+ 0.9% in the highest perception of access for urgent care, P < 0.01; + 1.2% for routine care, P < 0.001), leadership was supportive of the PCMH (+ 1.6% for urgent care, P < 0.01), and initiatives to improve access included open access (+ 0.8% to + 1.7% across all outcomes, P < 0.01) and telehealth visits (+ 1.2% to + 1.4%, P < 0.001). Perceived access was worse in clinics with moderate staff burnout (- 1.1% to - 1.4%, P < 0.001), primary care provider turnover during the past year (- 1.0% to - 1.6%, P < 0.001), or medical support assistant turnover in the past year (- 0.9% to - 1.4%, P < 0.001).

CONCLUSIONS

Perception of access was strongly associated with identifiable organizational factors and access-related initiatives within VA primary care clinics that could be adopted by other health systems.

Understanding Gender Sensitivity of the Health Care Workforce at the Veterans Health Administration

BACKGROUND

Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff.

METHODS

We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff.

RESULTS

PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff.

CONCLUSIONS

Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

Association of the Implementation of the Patient-Centered Medical Home with Quality of Life in Patients with Multimorbidity

BACKGROUND

The patient-centered medical home (PCMH) has clinical benefits for chronic disease care, but the association with patient-reported outcomes such as health-related quality of life (HRQoL) is unexplored in patients with multimorbidity (two or more chronic diseases).

OBJECTIVE

To examine if greater clinic-level PCMH implementation was associated with higher HRQoL in multimorbid adults.

DESIGN

A retrospective cohort study.

PARTICIPANTS

Twenty-two thousand ninety-five multimorbid patients who received primary care at 944 Veterans Health Administration (VHA) clinics.

MAIN MEASURES

Our exposure was the Patient Aligned Care Team Implementation Progress Index (PI²) for the clinic in 2012, a previously validated composite measure of PCMH implementation. Higher PI² scores indicate better performance within eight PCMH domains. Outcomes were patient-reported HRQoL measured by the physical and mental component scores (PCS and MCS) from the Short Form-12 patient experiences survey in 2013-2014. Interaction of the outcomes with total hospitalizations and primary care visit count was also examined. Generalized estimating equations were used for main models after adjusting for patient and clinic characteristics.

RESULTS

The cohort average age was 68 years, mostly male (96%), and had an average of 4.4 chronic diagnoses. Compared with patients seen at the lowest scoring clinics for PCMH implementation, care in the highest scoring clinics was associated with a higher adjusted marginal mean PCS (42.3 (95% CI 41.3-43.4) versus 40.3 (95% CI 39.1-41.5), P = 0.01), but a lower MCS (35.2 (95% CI 34.4-36.1) versus 36.0 (95% CI 35.3-36.8), P = 0.17). Patients with prior hospitalizations seen in clinics with higher compared with lower PI² scores had a 2.7 point greater MCS (95% CI 0.6-4.8; P = 0.01).

CONCLUSIONS

Multimorbid patients seen in clinics with greater PCMH implementation reported higher physical HRQoL, but lower mental HRQoL. The association between PCMH implementation and mental HRQoL may depend on complex interactions with disease severity and prior hospitalizations.

Does machine learning improve prediction of VA primary care reliance?

OBJECTIVES

The Veterans Affairs (VA) Health Care System is among the largest integrated health systems in the United States. Many VA enrollees are dual users of Medicare, and little research has examined methods to most accurately predict which veterans will be mostly reliant on VA services in the future. This study examined whether machine learning methods can better predict future reliance on VA primary care compared with traditional statistical methods.

STUDY DESIGN

Observational study of 83,143 VA patients dually enrolled in fee-for-service Medicare using VA and Medicare administrative databases and the 2012 Survey of Healthcare Experiences of Patients.

METHODS

The primary outcome was a dichotomous measure denoting whether patients obtained more than 50% of all primary care visits (VA + Medicare) from VA. We compared the performance of 6 candidate models-logistic regression, elastic net regression, decision trees, random forest, gradient boosting machine, and neural network-in predicting 2013 reliance as a function of 61 patient characteristics observed in 2012. We measured performance using the cross-validated area under the receiver operating characteristic (AUROC) metric.

RESULTS

Overall, 72.9% and 74.5% of veterans were mostly VA reliant in 2012 and 2013, respectively. All models had similar average AUROCs, ranging from 0.873 to 0.892. The best-performing model used gradient boosting machine, which exhibited modestly higher AUROC and similar variance compared with standard logistic regression.

CONCLUSIONS

The modest gains in performance from the best-performing model, gradient boosting machine, are unlikely to outweigh inherent drawbacks, including computational complexity and limited interpretability compared with traditional logistic regression.

Patient satisfaction with physician assistant/associate care: an international scoping review

BACKGROUND

As the role of the physician assistant/associate grows globally, one question is: what is the level of patient satisfaction with PAs? Driven by legislative enactments to improve access to care, the PA has emerged as a ready and able medical professional to address workforce shortages. The aim of this study was to review the literature on patient satisfaction of PAs.

OBJECTIVES

The basis for this review was to clarify working definitions, synthesize the evidence, and establish conceptual boundaries around the topic of patient satisfaction with PAs. The intent was to identify gaps in the literature and offer suggested undertakings for more clarification on the subject.

METHODS

A scoping review was undertaken. Literature from 1968 to 2019 was searched and filtered for eligibility. Those that met criteria were categorized by date, method, geography, themes, and design.

RESULTS

In total, there were 987 papers or reports that were identified through bibliography database searching. Additional articles found through snowball methodology-reviewing references (n = 11). Only English language articles emerged for analysis. From this effort, 25 articles surfaced from the filtering process for final inclusion. Most (72%) of the articles came from the United States of America, three from the United Kingdom, and one each from Ireland, the Netherlands, and New Zealand. Most articles were descriptive in nature. Some variations in methods emerged.

CONCLUSION

PAs are operational in 15 nations; their acceptance appears successful and satisfaction with their care largely indistinguishable from physicians. Findings from this analysis highlight one theory that when patient's needs are met, satisfaction is high regardless of the medical provider. Areas for further research are identified.

Factors of patient satisfaction in adult outpatient departments of private wing and regular services in public hospitals of Addis Ababa, Ethiopia: a comparative cross-sectional study

Background

Knowing the factors for patient satisfaction is an important and direct indicator of quality of health care which is essential for providers to fill their gaps. Although few studies have been conducted on patient satisfaction in Ethiopia; but there is limited evidence for comparing patient satisfaction and associated factors in the public and private wing of the health services. Thus, this study aimed to investigate factors of patient satisfaction in adult outpatient departments in the private wing and regular services at public hospitals of Addis Ababa, Ethiopia.

Methods

A comparative institution based cross-sectional study was conducted from March to April 2018. A total of 955 systematically selected patients were interviewed by using an interviewer-administered structured questionnaire. Binary logistic regression analysis was performed. In the multivariable logistic regression analysis p value < 0.05 and adjusted odd ratio (AOR) with 95% confidence interval (CI) were used to identify the associated factors.

Results

The overall patient satisfaction was 89.3% (95% CI: 87.2–91.2). At the regular and private wings of outpatient departments it was 88.3% (95% CI: 85.4–91.2) and 90.4% (95% CI: 87.6–93), respectively. At regular service OPD, patient satisfaction was affected by female sex (AOR: 7.78; 95% CI: 2.89–20.93), long waiting time (AOR: 0.22; 95% CI: 0.07–0.73), information on the prevention of recurrent illnesses (AOR: 14.16; 95% CI: 4.58–43.83), and information on drug use and side effects (AOR: 0.22; 95% CI: 0.08–0.63). In private wing, it was affected by being in the age group of 38 to 47 years (AOR: 22.1; 95% CI: 2.39–203.6), attended elementary school (AOR: 4.69; 95% CI: 1.04–21.26), availability of drugs (AOR: 0.14; 95% CI: 0.04–0.58), and the accessibility of latrines (AOR: 6.56; 95% CI: 1.16–37.11).

Conclusions

Patient satisfaction at the private wing and regular adult OPDs’ of public hospitals had no statistically significant difference. Female sex and information on the prevention of recurrent illnesses were factors positively affected patient satisfaction at regular services, whereas at private wing OPDs’ age, attended elementary school, and accessibility of latrines were factors that positively affected patient satisfaction.

Obesity and Health Care Experiences among Women and Men Veterans

BACKGROUND

Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care.

METHODS

Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n = 13,462 women, n = 268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics.

RESULTS

The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women.

CONCLUSIONS

It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.

Predicting Primary Care Use Among Patients in a Large Integrated Health System: The Role of Patient Experience Measures

OBJECTIVE

Most Veterans Affairs (VA) Health Care System enrollees age 65+ also have the option of obtaining care through Medicare. Reliance upon VA varies widely and there is a need to optimize its prediction in an era of expanding choice for veterans to obtain care within or outside of VA. We examined whether survey-based patient-reported experiences improved prediction of VA reliance.

METHODS

VA and Medicare claims in 2013 were linked to construct VA reliance (proportion of all face-to-face primary care visits), which was dichotomized (=1 if reliance >50%). We predicted reliance in 83,143 Medicare-eligible veterans as a function of 61 baseline characteristics in 2012 from claims and the 2012 Survey of Healthcare Experiences of Patients. We estimated predictive performance using the cross-validated area under the receiver operating characteristic (AUROC) curve, and assessed variable importance using the Shapley value decomposition.

RESULTS

In 2012, 68.9% were mostly VA reliant. The AUROC for the model including claims-based predictors was 0.882. Adding patient experience variables increased AUROC to 0.890. The pseudo R for the full model was 0.400. Baseline reliance and patient experiences accounted for 72.0% and 11.1% of the explained variation in reliance. Patient experiences related to the accessibility of outpatient services were among the most influential predictors of reliance.

CONCLUSION

The addition of patient experience variables slightly increased predictive performance. Understanding the relative importance of patient experience factors is critical for informing what VA reform efforts should be prioritized following the passage of the 2018 MISSION Act.

The Effect of Sociodemographic Factors on the Patient Satisfaction with Health Care System

The goal of this paper is to determine the level of patient satisfaction with health care among adults in the Republic of Serbia and to analyze the correlation between the satisfaction and socio-demographic characteristics of the interviewees. The paper is based on the data provided by the National health survey of the Republic of Serbia. For the purposes of this paper, we used data on age and household of the people aged 19 and more. By eliminating the interviewees who were neither satisfied nor dissatisfied with the health care services, we obtained the sample containing 18.206 interviewees. Demographic characteristics and well-being index represented independent variables in the research. Dependent variable of the patient satisfaction was transformed into a binary variable by categorizing satisfied and very satisfied interviewees into one group and by placing dissatisfied and very dissatisfied interviewees into group of dissatisfied patients. The connection between satisfaction and predictors was examined using Chi-Square test and logistic regression. The percentage of the satisfied patients with health care was 72.9%. The satisfaction level was directly connected to age, gender, marital status, employment, region the interviewee comes from and well-being index. Patients who were more satisfied included older people, women, as well as married people, the unemployed and those living in the cities. The analysis of the financial situation shows that the poorest interviewees were the most satisfied with health care.

Smoking Cessation among Female and Male Veterans before and after a Randomized Trial of Proactive Outreach

Introduction:

Female veterans smoke cigarettes at high rates compared with both male veterans and nonveteran women. Proactive outreach (PRO) to smokers may reduce gender disparities in cessation care. The objectives of this study were to compare baseline experiences with VA smoking cessation care for men and women and to assess for gender differences in response to a PRO intervention.

Methods:

We conducted a post hoc subgroup analysis of a pragmatic, multisite randomized, controlled trial comparing PRO with usual care (UC). Baseline experiences included physician advice to quit, satisfaction with care, and past-year treatment use. At the 1-year follow-up, treatment use, quit attempts, and 6-month prolonged abstinence for women and men randomized to PRO versus UC were compared using logistic regression.

Results:

Baseline and follow-up surveys were returned by 138 women and 2,516 men. At baseline, women were less likely than men to report being very or somewhat satisfied with the process of obtaining smoking cessation medications in the VA (47% of women vs. 62% of men), but no less likely to report having used cessation medications from the VA in the past year (39% of women vs. 34% of men). After the intervention, phone counseling and combined therapy increased among both women and men in PRO as compared with UC. At the 1-year follow-up, men in PRO were significantly more likely to report prolonged abstinence than those in UC (odds ratio, 1.65; 95% CI, 1.28–2.14); results for women were in the same direction but not statistically significant (odds ratio, 1.39; 95% CI, 0.48–3.99).

Conclusions:

Satisfaction with cessation care in VA remains low. PRO to smokers was associated with an increased use of cessation therapies, and increased odds of achieving prolonged abstinence. A subgroup analysis by gender did not reveal significant differences in the treatment effect.

Topical anesthetic techniques in office-based laryngeal surgery: A comparison of patient preferences

OBJECTIVES

Multiple topical anesthesia techniques exist for office-based laryngeal surgery. Our objective was to assess patient and surgeon satisfaction for three different techniques.

STUDY DESIGN

Cohort study.

METHODS

All consecutive patients presenting to an outpatient laryngology office for awake surgical procedures were enrolled. Patients were anesthetized with local anesthesia (2 cubic centimeters of 4% lidocaine) in one of three ways: 1) nebulizer, 2) flexible cannula through a channeled laryngoscope, or 3) transtracheal instillation. Demographics, procedure times, and surgeon satisfaction were recorded. A validated 11-item patient satisfaction questionnaire (Iowa Satisfaction with Anesthesia Survey) was administered after the procedure to calculate an overall satisfaction score (-3[worst] to 3[best]). Descriptive and correlative statistics were performed.

RESULTS

One hundred consecutive patients were included (37 females, 73 males), with relatively equal numbers between groups (32 nebulizer, 35 cannula, 33 transtracheal). Seven procedures were aborted (4 nebulizer, 2 cannula, 1 transtracheal) due to movement, anxiety, or technical issues. Three patients did not adequately complete the survey. Of the 90 remaining patients, patient satisfaction was highest with the transtracheal technique (2.04) versus cannula (1.46) or nebulizer (1.45), and this was statistically significant (P = 0.0167). This difference was driven by decreased pain and nausea scores in the transtracheal group. Surgeon satisfaction was lower with nebulizer and higher with transtracheal injection (P = 0.0081). There was a correlation between surgeon satisfaction and patient satisfaction (P < 0.0001).

CONCLUSION

Transtracheal instillation was favored by both patients and the surgeon. Choice of local anesthetic techniques may impact patient preferences and surgical success. This may serve as a basis for optimizing anesthetic care in office-based laryngeal surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:166-170, 2020.

Development of the Perceived Access Inventory: A patient-centered measure of access to mental health care

According to recent Congressional testimony by the Secretary for Veterans Affairs (VA), improving the timeliness of services is one of five current priorities for VA. A comprehensive access measure, grounded in veterans' experience, is essential to support VA's efforts to improve access. In this article, the authors describe the process they used to develop the Perceived Access Inventory (PAI), a veteran-centered measure of perceived access to mental health services. They used a multiphase, mixed-methods approach to develop the PAI. Each phase built on and was informed by preceding phases. In Phase 1, the authors conducted 80 individual, semistructured, qualitative interviews with veterans from 3 geographic regions to elicit the barriers and facilitators they experienced in seeking mental health care. In Phase 2, they generated a preliminary set of 77 PAI items based on Phase 1 qualitative data. In Phase 3, an external expert panel rated the preliminary PAI items in terms of relevance and importance, and provided feedback on format and response options. Thirty-nine PAI items resulted from Phase 3. In Phase 4, veterans gave feedback on the readability and understandability of the PAI items generated in Phase 3. Following completion of these 4 developmental phases, the PAI included 43 items addressing 5 domains: logistics (five items), culture (three items), digital (nine items), systems of care (13 items), and experiences of care (13 items). Future work will evaluate concurrent and predictive validity, test/retest reliability, sensitivity to change, and the need for further item reduction. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation

BACKGROUND

Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization.

METHODS/DESIGN

Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement.

DISCUSSION

VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.

Racial, Ethnic, and Gender Equity in Veteran Satisfaction with Health Care in the Veterans Affairs Health Care System

BACKGROUND

Patient satisfaction is an important dimension of health care quality. The Veterans Health Administration (VA) is committed to providing high-quality care to an increasingly diverse patient population.

OBJECTIVE

To assess Veteran satisfaction with VA health care by race/ethnicity and gender.

DESIGN AND PARTICIPANTS

We conducted semi-structured telephone interviews with gender-specific stratified samples of black, white, and Hispanic Veterans from 25 predominantly minority-serving VA Medical Centers from June 2013 to January 2015.

MAIN MEASURES

Satisfaction with health care was assessed in 16 domains using five-point Likert scales. We compared the proportions of Veterans who were very satisfied, somewhat satisfied, and less than satisfied (i.e., neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied) in each domain, and used random-effects multinomial regression to estimate racial/ethnic differences by gender and gender differences by race/ethnicity.

KEY RESULTS

Interviews were completed for 1222 of the 1929 Veterans known to be eligible for the interview (63.3%), including 421 white, 389 black, and 396 Hispanic Veterans, 616 of whom were female. Veterans were less likely to be somewhat satisfied or less than satisfied versus very satisfied with care in each of the 16 domains. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74-76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21-24% less than satisfied). None of the joint tests of racial/ethnic or gender differences in satisfaction (simultaneously comparing all three satisfaction levels) was statistically significant (p > 0.05). Pairwise comparisons of specific levels of satisfaction revealed racial/ethnic differences by gender in three domains and gender differences by race/ethnicity in five domains, with no consistent directionality across demographic subgroups.

CONCLUSIONS

Our multisite interviews of a diverse sample of Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender.

"I Think It's Pretty Much the Same, as It Should Be": Perspectives of Inpatient Care Among Women Veterans

The purpose of this study was to gain a deeper understanding of the inpatient hospitalization experience for women veterans through in-depth interviews. Women veterans who were admitted for inpatient care on medical units within a university-affiliated VA hospital were invited to participate in a semistructured interview that inquired about their hospital experience, interactions with medical providers, and how being a woman veteran might affect this experience. Interviews were transcribed verbatim and analyzed using constant comparative method until thematic saturation was achieved ( n = 25). Three themes, (a) Being a woman and a veteran: Intersecting identities, (b) Expecting equality and equity, and (c) Defining woman-centered inpatient care described the unique perspective and context for Veterans Health Administration (VHA) health care of women veterans. These findings provide insight and guidance to clinical practice and care delivery for women veterans, including training and interpersonal approaches medical providers can take to improve the hospital experience for women.

Patient Activation and Mental Health Care Experiences Among Women Veterans

We utilized a nationally representative survey of women veteran primary care users to examine associations between patient activation and mental health care experiences. A dose-response relationship was observed, with odds of high quality ratings significantly greater at each successive level of patient activation. Higher activation levels were also significantly associated with preference concordant care for gender-related preferences (use of female providers, women-only settings, and women-only groups as often as desired). Results add to the growing literature documenting better health care experiences among more activated patients, and suggest that patient activation may play an important role in promoting engagement with mental health care.

Transgender Veterans' Satisfaction With Care and Unmet Health Needs

BACKGROUND

Transgender individuals are overrepresented among Veterans. However, little is known regarding their satisfaction with Veterans Administration (VA) care and unmet health needs.

OBJECTIVES

This study examined transgender Veterans' satisfaction with VA medical and mental health care, prevalence of delaying care, and correlates of these outcomes.

RESEARCH DESIGN

We used data from transgender Veterans collected in 2014 through an online, national survey.

SUBJECTS

In total, 298 transgender Veterans living in the United States.

MEASURES

We assessed patient satisfaction with VA medical and mental health care and self-reported delays in seeking medical and mental health care in the past year. Potential correlates associated with these 4 outcomes included demographic, health, and health care variables.

RESULTS

Over half of the sample used VA (56%) since their military discharge. Among transgender Veterans who had used VA, 79% were satisfied with medical care and 69% with mental health care. Lower income was associated with dissatisfaction with VA medical care, and being a transgender man was associated with dissatisfaction with VA mental health care. A substantial proportion reported delays in seeking medical (46%) or mental (38%) health care in the past year (not specific to VA). Screening positive for depression and/or posttraumatic stress disorder was associated with delays in seeking both types of care.

CONCLUSIONS

Although the majority of transgender Veterans are satisfied with VA health care, certain subgroups are less likely to be satisfied with care. Further, many report delaying accessing care, particularly those with depression and/or posttraumatic stress disorder symptoms. Adapting health care settings to better engage these vulnerable Veterans may be necessary.

Experiences with VHA care: a qualitative study of U.S. women veterans with self-reported trauma histories

BACKGROUND

Women veterans in the United States, particularly those with posttraumatic stress disorder (PTSD) or a history of military sexual assault, have unique health care needs, but their minority status in the US Veterans Health Administration (VHA) has led to documented healthcare disparities when compared to men. This study's objective was to obtain a richer understanding of the challenges and successes encountered by women veterans with self-reported service-related trauma histories (particularly those with a history of military sexual assault and/or posttraumatic stress symptomology) receiving VHA care.

METHODS

Thirty-seven female Vietnam and post-Vietnam (1975-1998) era veterans were randomly selected from a cohort of PTSD disability benefit applicants to complete semi-structured interviews in 2011-2012. Grounded-theory informed procedures were used to identify interview themes; differences between veterans with and without a history of military sexual assault were examined through constant comparison.

RESULTS

At the time of the interviews, many women believed that VHA was falling short of meeting women veterans' needs (e.g., lack of women-only mental health programming). Also common, but particularly among those with a military sexual assault history, was the perception that VHA's environment was unwelcoming; being "surrounded by men" yielded emotions ranging from discomfort and mistrust to severe anxiety. A few veterans reported recent positive changes and offered additional suggestions for improvement.

CONCLUSIONS

Findings suggest that while at the time of the interviews gains had been made in the delivery of gender-sensitive outpatient medical care, women veterans with a history of military sexual assault and/or posttraumatic stress symptomology perceived that they were not receiving the same quality of care as male veterans.

Patient satisfaction with medical consultations among adults attending Mulago hospital assessment centre

Background

Patient satisfaction is known to positively influence patients’ compliance with medical advice. In Africa, and specifically Uganda, this interaction has rarely been put to scientific inquiry. This study aimed to determine the level of patient satisfaction and identify factors influencing satisfaction with medical consultations among adults attending Mulago Assessment Centre.

Methods

This was a quantitative descriptive cross-sectional study where 384 respondents were interviewed using a structured questionnaire adapted from the Medical Interview Satisfaction Scale (MISS-21) with a four-point Likert scale. Patient satisfaction was measured using four dimensions namely: information provision, clinicians’ communication skills, perceived consulting time and patient’s confidence in the clinician. Respondents’ mean scores were categorised as satisfied or dissatisfied. Multivariate linear regression analysis assessed the effect of independent variables on the regression factor score of the dependent variable. Significance level was set at p < 0.05. Final data analysis was done using STATA version 11.0.

Results

Of the sample, 53.9% were satisfied with the medical consultation. Patients’ average scores showed lowest satisfaction for information provision (2.7 points) compared with communication skills (3.22 points), patient confidence in the clinicians (3.22 points) and consultation time (3.05 points). Being older, employed, living further away from the health centre and frequently visiting the centre were positively associated with patient satisfaction.

Conclusions

Patient satisfaction was largely affected by interpersonal factors. This highlights the need for training of clinicians on the importance of adequate information provision, good communication skills and technical competences like thorough examination of patients and relieving worries about illness during the consultation.

Changes in Patient-Reported Alcohol-Related Advice Following Veterans Health Administration Implementation of Brief Alcohol Interventions

OBJECTIVE

Brief alcohol interventions are recommended for primary care patients who screen positive for alcohol misuse, but implementation is challenging. The U.S. Veterans Health Administration (Veterans Affairs [VA]) implemented brief interventions for patients with alcohol misuse in 2008, and rates of brief interventions documented in the electronic medical record increased from 24% to 78% (2008-2011). This study examined whether an independent measure of brief interventions-patient-reported alcohol-related advice-also increased among VA outpatients who screened positive for alcohol misuse on a mailed survey.

METHOD

This retrospective cross-sectional study included VA outpatient respondents to the VA's Survey of Healthcare Experiences of Patients (SHEP; 2007-2011) who reported past-year alcohol use and answered a question about alcohol-related advice. Alcohol-related advice was defined as a report of past-year advice from a VA clinician to abstain from or reduce drinking. The adjusted prevalence of alcoholrelated advice among patients who screened positive for alcohol misuse (SHEP AUDIT-C ≥ 5) was estimated for each year.

RESULTS

Among patients with alcohol misuse (n = 61,843), the adjusted prevalence of alcohol-related advice increased from 40.4% (95% CI [39.3%, 41.5%]) in 2007 to 55.5% (95% CI [53.3%, 57.8%]) in 2011. Rates of alcoholrelated advice increased significantly each year except the last.

CONCLUSIONS

The VA's efforts to implement brief interventions were associated with increased patient-reported alcohol-related advice over time, with a majority of patients with alcohol misuse reporting its receipt. Other systems considering similar approaches to implementation may benefit from collecting patient-reported measures of brief interventions for an additional perspective on implementation.

Low Self-Reported Function Predicts Adverse Postoperative Course in Veterans Affairs Beneficiaries Undergoing Total Hip and Total Knee Replacement

OBJECTIVES

To measure association between self-reported function and an adverse postoperative course and improvement in performance on the American College of Surgeons Universal Risk Calculator (ACS calculator) with inclusion of self-reported function available through the Veteran Rand-12 based Physical Component Summary (PCS) and Mental Component Summary (MCS) scores.

DESIGN

Cohort analysis.

SETTING

Veteran Affairs health system.

PARTICIPANTS

Surgeries (n = 3,503) for older male veterans undergoing hip and knee replacement from 2002 to 2009.

MEASUREMENTS

Serious complication (per ACS definition), discharge to facility, readmission, and death within 30 days after surgery as a function of PCS and MCS; comparison of prediction of net reclassification index (NRI) for serious complication using a modified version of the ACS calculator with prediction using the ACS calculator with MCS and PCS added.

RESULTS

Being in the lowest PCS quartile (vs highest quartile) predicted more than twice the risk of a serious complication (odds ratio (OR) = 2.27, 95% confidence interval (CI) = 1.44-3.58), twice the risk of discharge to facility (OR = 1.97, 95% CI = 1.39-2.79), and almost twice the risk of readmission (OR = 1.80, 95% CI = 1.37-2.36). The lowest quartile of MCS predicted each outcome, although to a lesser extent than PCS. The enhanced model had a NRI of 29.4% (95% CI = 15.4-43.3%), reflecting that 20.8% of events were appropriately upgraded and 8.6% of nonevents appropriately downgraded.

CONCLUSION

Low PCS and MCS predicted an adverse postoperative course and enhanced the ACS calculator. Clinicians evaluating older adults undergoing orthopedic surgery could enhance the accuracy of their assessments by including self-reported functional status.

Satisfaction and associated factors of outpatient psychiatric service consumers in Ethiopia

PURPOSE

The purpose of this study was to assess the level of patient satisfaction and associated factors with psychiatric outpatient services in Ethiopia.

PATIENTS AND METHODS

A cross-sectional study was performed from May 2015 to June 2015. A total of 454 participants selected by systematic random sampling were included in this study. Pretested and interviewer-administered questionnaire was used to collect the data. Patient satisfaction was measured using Charleston Psychiatric Outpatient Satisfaction Scale, and other validated tools were used to assess the associated variables. Multivariate logistic regressions with 95% confidence interval (CI) were used to assess the strength, and P-value <0.05 was used to indicate significance of association.

RESULTS

A total of 441 respondents were enrolled, with a response rate of 97.1% and magnitude of satisfaction of 61.2%. Being male (adjusted odds ratio [AOR] =0.612, 95% CI: 0.39, 0.94), being widowed (AOR =0.13, 95% CI: 0.05, 0.36), urban residence (AOR =0.49, 95% CI: 0.31, 0.78), diagnosed with schizophrenia (AOR =0.48, 95% CI: 0.28, 0.81), unfavorable attitude (AOR =0.49, 95% CI: 0.28, 0.86), and poor social functioning (AOR =0.52, 95% CI: 0.34, 0.80) were significantly associated with satisfaction.

CONCLUSION

More than one-third of psychiatric service consumers were dissatisfied with the service they received. Integrating patients to their own treatment plan and regular service evaluation are important to improve satisfaction.

Women Veterans' Pathways to and Perspectives on Veterans Affairs Health Care

BACKGROUND

We examined Veterans Affairs (VA) health care experiences among contemporary women veteran patients receiving care at a VA medical center. Specifically, we examined women veteran patients' satisfaction with VA care along dimensions in line with patient-centered medical home (patient-aligned care teams [PACT] in VA) priorities, and pathways through which women initially accessed VA care.

METHODS

We used a mixed methods research design. First, 249 racially diverse women (ages 22-64) who were past-year users of primary care at a VA medical center completed interviewer-administered surveys in 2012 assessing ratings of satisfaction with care in the past year. We then conducted in-depth qualitative interviews of a subset of women surveyed (n = 25) to gain a deeper understanding of perspectives and experiences that shaped satisfaction with care and to explore women's initial pathways to VA care.

RESULTS

Ratings of satisfaction with VA care were generally high, with some variation by demographic characteristics. Qualitative interviews revealed perceptions of care centered on the following themes: 1) barriers to care delay needed medical care, while innovative care models facilitate access, 2) women value communication and coordination of care, and 3) personalized context of VA care, including gender sensitive care shapes women's perceptions. Pathways to VA care were characterized by initial delays, often attributable to lack of knowledge or negative perceptions of VA care. Informal social networks were instrumental in helping women to overcome barriers.

CONCLUSIONS

Findings highlight convergence of women's preferences with PACT priorities of timely access to care, provider communication, and coordination of care, and suggest areas for improvement. Outreach is needed to address gaps in knowledge and negative perceptions. Initiatives to enhance women veterans' social networks may provide an information-sharing resource.

Association Between Receipt of Brief Alcohol Intervention and Quality of Care among Veteran Outpatients with Unhealthy Alcohol Use

BACKGROUND

Brief alcohol intervention, including advice to reduce or abstain from drinking, is widely recommended for general medical outpatients with unhealthy alcohol use, but it is challenging to implement. Among other implementation challenges, providers report reluctance to deliver such interventions, citing concerns about negatively affecting their patient relationships.

OBJECTIVE

The purpose of this study was to determine whether patient-reported receipt of brief intervention was associated with patient-reported indicators of high-quality care among veteran outpatients with unhealthy alcohol use.

DESIGN

Cross-sectional secondary data analysis was performed using the Veterans Health Administration (VA) Survey of Healthcare Experiences of Patients (SHEP).

PARTICIPANTS

The study included veteran outpatients who (1) responded to the outpatient long-form SHEP (2009-2011), (2) screened positive for unhealthy alcohol use (Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire score ≥ 3 for women, ≥ 4 for men), and (3) responded to questions assessing receipt of brief intervention and quality of care.

MAIN MEASURES

We used logistic regression models to estimate the adjusted predicted prevalence of reporting two indicators of high-quality care--patient ratings of their VA provider and of overall VA healthcare (range 0-10, dichotomized as ≥ 9 indicating high quality)--for both patients who did and did not report receipt of brief intervention (receiving alcohol-related advice from a provider) within the previous year.

KEY RESULTS

Among 10,612 eligible veterans, 43.8% reported having received brief intervention, and 84.2% and 79.1% rated their quality of care as high from their provider and the VA healthcare system, respectively. In adjusted analyses, compared to veterans who reported receiving no brief intervention, a higher proportion of veterans reporting receipt of brief intervention rated the quality of healthcare from their provider (86.9% vs. 82.0%, p < 0.01) and the VA overall (82.7% vs. 75.9%, p < 0.01) as high.

CONCLUSIONS

In this cross-sectional analysis of veterans with unhealthy alcohol use, a higher proportion of those who reported receipt of brief intervention reported receiving high-quality care compared to those who reported having received no such intervention. These findings do not support provider concerns that delivering brief intervention adversely affects patients' perceptions of care.

Comparison of provider-documented and patient-reported brief intervention for unhealthy alcohol use in VA outpatients

BACKGROUND

Performance measures for brief alcohol interventions (BIs) are currently based on provider documentation of BI. However, provider documentation may not be a reliable measure of whether or not patients are offered clinically meaningful BIs. In particular, BI documented with clinical decision support in an electronic medical record (EMR) could appear identical irrespective of the quality of BI provided. We hypothesized that differences in how BI was implemented across health systems could lead to differences in the proportion of documented BI recalled and reported by patients across health systems.

METHODS

Male outpatients with unhealthy alcohol use identified by confidential satisfaction surveys (2009-2012) were assessed for whether they reported receiving BI in the past year (patient-reported BI) and whether they had BI documented in the EMR during the same period (documented BI). We evaluated and compared the prevalence of documented BI to patient-reported BI across 21 VA networks to determine whether documented BI had a variable association with patient-reported BI across the networks.

RESULTS

Of 9896 eligible male outpatients with unhealthy alcohol use, 59.0% (95% CI 57.4-60.5%) reported BI (50.4-64.9% across networks) and 37.4% (95% CI 36.0-38.9%) had BI documented in the EMR (28.0-44.2% across networks). Overall, 72.9% (95% CI 70.8-75.5%) of patients with documented BI also reported BI. The association between documented BI and patient-reported BI did not vary across VA networks in adjusted logistic regression models.

CONCLUSIONS

Performance measures of BI that rely on provider documentation in EMRs appear comparable to patient report for comparing care across VA networks.

Local Area Unemployment and the Demand for Inpatient Care Among Veterans Affairs Enrollees

Prior research examining the relationship between economic conditions and health service demand has focused primarily on outpatient use. This study examines whether local area unemployment, as an indicator of economic conditions, was associated with use of inpatient care, which is theoretically less subject to discretionary use. Using a random sample of 131,603 patients dually enrolled in the Veterans Affairs (VA) Health System and fee-for-service Medicare, we measured VA, Medicare, and total (VA and Medicare) hospitalizations. Overall, local unemployment was not associated with VA, Medicare, or total hospitalization probability. Among low-income veterans exempt from VA copayments, higher local unemployment was moderately associated with a lower probability of hospitalization through Medicare. For veterans subject to VA copayments, higher local unemployment was moderately associated with a higher likelihood of VA hospitalization. These results suggest inpatient use is less sensitive to the economy, although worse economic conditions slightly affected inpatient demand for select veterans.