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Primary Care Quality and Patient Satisfaction in Rural and Urban Veterans Health Administration Settings

Stolzman KL, Benzer JK, Meterko MM, Osatuke K, Mohr DC. Primary Care Quality and Patient Satisfaction in Rural and Urban Veterans Health Administration Settings. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 5; Portland, ME.

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Objectives: The objective of this study was to compare rural and urban settings with regard to primary care patient satisfaction and technical quality of care using a large national sample of patients who received care through the Veterans Health Administration (VA). Methods: We measured patient satisfaction using data from the 2007 Survey of Health Experiences of Patients (SHEP). The outpatient SHEP includes a single-item assessment of overall quality and eight multi-item scales measuring specific dimensions of satisfaction with care (access, continuity of care, visit coordination, overall coordination, emotional support, patient education, patient preferences, and courtesy). Average scale scores were computed for each facility (STA5A designation), including only facilities with at least 30 patient responses for primary care (51 rural and 141 urban VA facilities). The 2007 External Peer Review Program (EPRP) data were used to calculate measures of technical quality based on adherence to best practice guidelines in five disease-specific domains (diabetes, acute myocardial infarction (AMI), hypertension, cancer screening, and immunizations). Disease-specific adherence measures for each VA facility (STA5A) were calculated by dividing the number of preventive medicine recommendations fulfilled and/or intermediate outcome levels achieved by the total number eligible at each facility. Only facilities with at least 30 eligible patients for the disease-specific composites were included. The AMI composite had the lowest number of eligible patients (22 rural and 78 urban VA facilitates). The hypertension composite had the highest number of patients eligible (41 rural and 134 urban VA facilitates). PROC TTEST was used for univariate analyses and PROC GLM for linear regression models (SAS, version 9.1). Results: For patient satisfaction, we observed a trend toward higher scores for rural facilities on overall quality (80.4 vs. 78.2; p = 0.07) and access (85.8 vs. 83.0; p = 0.002). These differences persisted after adjusting for type of facility (medical hospital or community-based outpatient clinic (CBOC)), region (Northeast, Midwest, Southern, Western), and land area of county (square miles). The unadjusted technical quality of care measures between rural and urban VA facilities was not significantly different. Adjusting for type of facility, region, and land area using linear regression models did not change the findings. Implications: Patient satisfaction with access was significantly higher at primary care practices in rural facilities, which also demonstrated somewhat higher scores on perceptions of overall quality. The SHEP access scale included items about ease of scheduling clinic appointments, satisfaction with wait times, and amount of time spent with the provider. The technical quality of care among five disease-specific composite measures was not significantly different for rural and urban settings. Impacts: Rural facilities had higher satisfaction scores on a few key dimensions, notably access. However, several potentially important facets of access related to geographic and/or financial considerations, such as drive time and the availability of evening (after work) clinic hours, were not represented in the access scale used here. Additional research is needed to explore these important dimensions of access and examine clinic scheduling and operations issues that may also influence patient satisfaction with access.

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