The Non-Veteran Experience at Veterans Affairs Medical Centers During the COVID-19 Pandemic: a Survey-Based Study

INTRODUCTION

In April 2020, the VA Ann Arbor Healthcare System (AAVA) and the VA Detroit Medical Center (DVA) began caring for non-Veteran patients in the midst of the COVID-19 pandemic,^1,2 subsequently caring for the second and third most non-Veteran patients in the nation, respectively. In a first-of-its-kind study, we sought to understand non-Veteran perceptions of the quality of care provided at VA medical centers.

METHODS

Patients were transferred to the AAVA or DVA from southeast Michigan hospitals that had no additional bed capacity, without differentiation for patient acuity or COVID status. These patients were contacted by a trained nurse within 2 weeks of hospital discharge via telephone to complete a 13-question survey about their experiences. Exclusion criteria were death during the hospitalization, discharge to hospice, diagnosis of dementia, re-hospitalization within the follow-up period, or non-response to follow-up calls. We called patients three times prior to exclusion.

Patient data were aggregated to identify opportunities for improvement across both VA hospitals. Descriptive statistics (means, percentages) and standard deviation (SD) were used to tabulate survey responses. Bivariate comparisons were assessed using Fisher’s exact and logistic regression, as appropriate. For bivariate data analyses, the proportion of participants who were satisfied (“very” or “somewhat” satisfied) were compared with those who were dissatisfied (“very” dissatisfied, “somewhat” dissatisfied, or “neither satisfied nor dissatisfied”). When comparing hospitalizations, responses reporting similar or superior care at VA medical centers were summed and compared to responses reporting inferior care at VA medical centers. A two-sided p value of ≤ 0.05 was considered statistically significant.

This work meets the criteria for non-research operations activities as outlined by the Department of Veterans Affairs Office of Research and Development³; thus, IRB approval was deemed unnecessary.

RESULTS

A total of 55 non-Veteran patients were transferred to VA facilities in Michigan (33 AAVA, 22 DVA). Thirteen patients died while hospitalized (7 at AAVA, 6 at DVA) and 4 were excluded (1 discharged to hospice, 2 with dementia, 1 re-hospitalized). Of the remaining 38 eligible patients, 15 were unreachable by telephone, yielding a response rate of 60.5%.

Baseline characteristics of the 23 included non-Veteran patients are illustrated in Table 1. No differences in outcomes were noted when analyzed by patient sex or VA medical center. Overall, 20 (87.0%) participants were satisfied with VA care and 18 (78.3%) responded that they were somewhat or very likely to recommend VA care to others (Table 2).

Table 1.

Baseline Characteristics of Participants

	Total (N = 23)
Gender, N (%)
Male	15 (65.2%)
Female	8 (34.8%)
Age in years, mean (SD*)	55.0 (13.4)
Length of stay in days, mean (SD*)	5.6 (4.4)
COVID status on admission, N (%)
Positive	18 (78.3%)
Negative	3 (13.0%)
Person under investigation	2 (8.7%)
Mechanical ventilation, N (%)
No	21 (91.3%)
Yes	2 (8.7%)
Intensive care unit, N (%)
No	18 (78.3%)
Yes	5 (21.7%)
Days spent at previous facility, N (%)
Less than 1 day	14 (60.9%)
1 day or more	9 (39.1%)
Discharge destination, N (%)
Home	21 (91.3%)
Hospital	1 (4.3%)
Skilled nursing facility	1 (4.3%)

*SD, standard deviation

Table 2.

Participant Survey Responses

Overall experience with VA medical centers	Total (N = 23) N (%)
How satisfied were you with the overall care you received at the VA?
Very Satisfied   Somewhat Satisfied   Neither Satisfied nor Dissatisfied   Somewhat Dissatisfied   Very Dissatisfied	17 (73.9%) 3 (13.0%) 0 2 (8.7%) 1 (4.3%)
If everyone – not just Veterans - could come to the VA, how likely would you be to recommend the VA as a facility to others?
Very Likely   Somewhat Likely   Neither Unlikely nor Likely   Somewhat Unlikely   Very Unlikely	17 (73.9%) 1 (4.3%) 1 (4.3%) 1 (4.3%) 3 (13.0%)
Comparing the VA Medical Centers to Transferring Hospital	Total (N = 23) N (%)
Comparing your recent experience at the VA to the hospital you were transferred from, where did you feel that you received better overall care?
VA   The care was about the same   Other facility	11 (47.8%) 10 (43.5%) 2 (8.7%)
How would you rate care provided to you by physicians at the VA compared to the hospital you were transferred to the VA from?
Better   About the same   Worse   Not sure	11 (47.8%) 11 (47.8%) 1 (4.3%) 0
How would you rate care provided to you by nurses at the VA compared to the hospital you were transferred to the VA from?
Better   About the same   Worse   Not sure	15 (65.2%) 6 (26.1%) 2 (8.7%) 0
How would you rate how doctors, nurses, and other staff communicated with you and your family at the VA compared to the hospital you were transferred to the VA from?
Better   About the same   Worse   Not sure	10 (43.5%) 12 (52.2%) 0 1 (4.3%)
Comparing VA Medical Centers to Previous Hospitalizations	Total (N = 11) N (%)
Thinking back to all your hospitalizations at other healthcare facilities, in comparison to your experience at the VA, where did you feel that you received better care?
VA   They were about the same   Other facility   Not sure	4 (36.4%) 5 (45.4%) 2 (18.2%) 0
How would you rate physician care at the VA compared to other hospitals you have experienced in the past?
Better   About the same   Worse   Not sure	7 (63.6%) 4 (36.4%) 0 0
How would you rate nursing care at the VA compared to other hospitals you have experienced in the past?
Better   About the same   Worse   Not sure	7 (63.6%) 3 (27.3%) 1 (9.1%) 0
How would you rate how doctors, nurses, and other staff communicated with you and your family at the VA compared to other hospitals you have experienced in the past?
Better   About the same   Worse   Not sure	6 (54.5%) 5 (45.4%) 0 0
How would you rate discharge instructions you were given at the VA compared to discharge instructions you have received from other hospitals in the past?
Better   About the same   Worse   Not sure	3 (27.3%) 7 (63.6%) 1 (9.1%) 0

Compared to care received at the transferring facility, 21 (91.3%) felt that overall VA care was the same or better. Most participants felt that care delivered by VA physicians (n = 22, 95.6%) and VA nursing (n = 21, 91.3%) was the same as or better than care at the transferring facility. Similarly, 22 participants (95.6%) felt that communication from VA physicians, nurses, and staff was the same as or better than at the transferring facility.

A total of 11 (47.8%) participants reported hospitalizations any time before their most recent episode of illness. Of those, nine (81.8%) reported that overall VA care was the same as or better than care at the other hospital. Eleven (100%) and 10 (90.9%) participants reported that VA physician and VA nursing care was the same as or better than care at other facilities, respectively. All participants reported that communication at VA was the same as or better than communication during prior hospitalizations; 10 (90.9%) participants reported that the quality of VA discharge documentation was the same as or better than that received at discharge from prior hospitalizations.

DISCUSSION

In our direct examination of non-Veterans’ experiences at VA medical centers, non-Veterans perceived the VA favorably in terms of overall care, physician care, nursing care, and communication when compared to transferring facilities and other hospitals. In general, non-Veterans were highly satisfied with the care received at the VA and often preferred VA care over non-VA care. Other published studies have demonstrated that the quality of care delivered by VA is similar to, if not better than, non-VA hospitals.^4–7 Limitations of our study include the small sample size, potential bias created by our exclusion criteria, and the possible propensity to report satisfaction with care during a pandemic. Our study, however, adds to the literature through the novel lens of the non-Veteran patient experience.

Declarations

Conflict of Interest

All authors are employed by the US Department of Veterans Affairs. Dr. Gupta reports receiving grant funding from the Moore Foundation. Neither Drs. Brown, Harrod, Houchens, nor Hausman report any disclosures. Dr. Saint reports receiving grants from the Department of Veterans Affairs and personal fees from ISMIE Mutual Insurance Company, Jvion, and Doximity.