Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1053 — What Drives Veteran Quality Ratings In and Outside the VA: Findings from the Women Veterans' Health Experience Survey

Lead/Presenter: Catherine Chanfreau, COIN - Los Angeles
All Authors: Chanfreau-Coffinier C (VA Los Angeles HSR&D COIN) Darling JE (VA Los Angeles HSR&D COIN) Canelo I (VA Los Angeles HSR&D COIN) Yano EM (VA Los Angeles HSR&D COIN and UCLA)

Objectives:
Increased referral to community care aims to reduce waits and delays, yet little is known about Veterans' experience with VA versus non-VA care. In particular, women Veterans (WVs) have high rates of community referrals given local VA facilities' variable ability to meet their needs. We examined WVs' patient experience contrasting those who use VA care-only and dual users of VA and non-VA care.

Methods:
We surveyed a population-based random sample of 1395 WVs with 3+ visits for primary care (PC) and/or women's healthcare (WHC) at 12 VA sites. We asked patients to rate the quality of overall VA care, WHC, and PC. Experience measures included ease of access to services and provider communication from VA's Consumer Assessment of Health Plans/Patient-Centered Medical Home (CAHPS/PCMH); and perception of feeling welcome at VA as a woman. Multivariate models were adjusted for sociodemographics, overall health, and survey design. We tested mediation pathways using nested models with residual inclusions.

Results:
Ease of access, provider communication, and feeling welcome at VA were positively associated with WVs' quality-of-care ratings (each, P < 0.001). High quality ratings were more likely among VA-only users than dual users (OR, 1.57, 95%CI(1.14-2.17) for VA; 1.65, 95%CI(1.20-2.27) for WHC; 1.41, 95%CI(1.10-1.82) for PC). While the two groups rated ease of access similarly, VA-only users were more likely to give high ratings for provider communication (OR 1.52; 95%CI (1.23-1.89)) and feeling welcome (2.15; 95%CI(1.48-3.12)). Mediation analysis provided support for two paths linking receiving all care at VA and quality ratings, one through provider communication (30% of effects on VA and WHC ratings, 60% for PC) and another via feeling welcome (18% for VA and WHC, 30% for PC).

Implications:
High ratings of overall VA care, PC and WHC were more likely among VA-only users than among dual users, and this effect was mediated by the quality of provider communication and feeling welcome at VA.

Impacts:
Expanding access by increasing referrals to community care runs the risk of fragmenting care. Our work draws attention to potential negative impacts on patient experience among WVs used to receiving all care at VA, particularly if no simultaneous consideration is given to provider communication.