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Publication Briefs

Study Shows Veterans Using VA and Non-VA Care Experience More Healthcare "Hassles" than Veterans Using VA Care Only

VA increasingly pays for care to be provided to its patients by non-VA providers in the community, which may improve access to care, but could complicate care coordination. Recognized as a measure of care coordination, the Hassles scale (16-item Health Care System Hassles Scale) lists problems that patients, especially those with greater medical complexity, may encounter with their general healthcare, as opposed to their care experience during one specific visit or with one specific provider. Investigators in this study compared "hassles" experienced by Veterans receiving VA healthcare only versus those receiving dual care from both VA and non-VA community providers. Investigators analyzed survey data from 2017-2018 from 2,444 randomly selected Veterans with four or more primary care visits in the prior year at one of 12 VA primary care clinics in four geographically diverse regions of the U.S. Covariates included participants' sociodemographic characteristics (sex, age group, race/ethnicity, education, and marital status) and self-reported ratings of overall physical and mental health status.


  • Controlling for sociodemographics and self-rated physical and mental health, dual-care users experienced more hassles than VA-only users (adjusted predicted average 5.5 vs. 4.3 hassles).
  • The overall number of reported hassles ranged from 0 to 16, with 79% of Veterans reporting that they experienced one or more hassles. The top five hassles were: 1) long waits for an appointment for specialty providers or clinics (56%); 2) poor communication between different healthcare providers (44%); 3) lack of information about which treatment options are best for your medical conditions (41%); 4) lack of information about your medical conditions (40%); and 5) difficulty getting questions answered or getting medical advice between scheduled appointments (40%).
  • Significantly higher proportions of Veterans who received their healthcare from VA providers only rated their health as “good,” “very good,” or “excellent” compared to Veterans who received dual care (physical health: 64% vs 56%; mental health: 72% vs 66%).


  • Anticipated increases in Veterans accessing community-based care may require new strategies to help VA primary care teams optimize care coordination for dual care users.


  • Dual-care users in this study sample reported both worse physical and mental health, which may signal that they were sicker in other ways that the study could not control for.
  • The Hassles scale may not have captured more nuanced factors that could inform opportunities for improved care coordination or best practices.
  • Investigators did not assess specific factors that may have contributed to Veterans’ use of non-VA care, such as other forms of insurance, geographical access, wait times, or some other barrier.

This study was funded through the Quality Enhancement Research Initiative (QUERI). Dr. Ganz co-leads the Care Coordination QUERI. Drs. Noël, Finley, and Penney are part of The Elizabeth Dole Center of Excellence for Veteran & Caregiver Research; Drs. Ganz, Lee, Olmos-Ochoa, Chawla, and Rose, and Mss. Barnard, Barry, and Simon are part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP).

Noël P, Barnard J, Barry F, Simon A, Lee M, Olmos-Ochoa T, Chawla N, Rose D, Stockdale S, Finley E, Penney L, and Ganz D. Patient Experience of Healthcare System Hassles: Dual System vs. Single System Users. Health Services Research. May 7, 2020; Epub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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