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Many Veterans receive Department of Veterans Affairs (VA)-purchased care from non-VA facilities but little is known about factors that Veterans consider for this choice. Between May 2020 and August 2021, we surveyed VA-purchased care-eligible VA patients about barriers and facilitators to choosing where to receive care. We examined the association between travel time to their VA facility and their choice of VA-purchased care (VA-paid health care received in non-VA settings) versus VA facility and whether this association was modified by distrust. We received 1,662 responses and 692 (42%) chose a VA facility. Eighty percent reported quality care was in their top three factors that influenced their decision. Respondents with the highest distrust and who lived >1 hr from the nearest VA facility had the lowest predicted probability (PP) of choosing VA (PP 15%; 95% confidence interval: 10%-20%). Veterans value quality of care. VA and other health care systems should consider patient-centered ways to improve and publicize quality and reduce distrust.
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Hospitales de Veteranos , United States Department of Veterans Affairs , Veteranos , Humanos , Estados Unidos , Femenino , Masculino , Veteranos/psicología , Persona de Mediana Edad , Anciano , Calidad de la Atención de Salud , Encuestas y Cuestionarios , Motivación , Conducta de Elección , Accesibilidad a los Servicios de Salud , Adulto , ConfianzaRESUMEN
Objectives: This study was designed to understand the experience and needs surrounding advance care planning (ACP) discussions for surrogate decision-makers of persons with advanced dementia (PWAD). Methods: Semi-structured qualitative interviews based on end-of-life communication models with a convenience sample of 17 clinicians, and 15 surrogates of PWAD. We used a hybrid approach of deductive and inductive thematic analysis. Results: Two main themes emerged. 1)Deficits in communication: Often surrogates did not fully comprehend the disease trajectory or medical treatments, like the likelihood of pneumonia and use of mechanical ventilation, nor concepts related to ACP, particularly legal documents and orders such as Do Not Hospitalize, which made decision-making challenging as perceived by clinicians. 2)Decision-making conflicts: Clinicians perceived a disconnect between surrogates' understanding of their loved one's preferences and knowing how or when to operationalize them. Conclusions: Significant gaps in knowledge surrounding disease trajectory and complications, such as pneumonia, and aspects of ACP, exist. These gaps create decision-making challenges for surrogates and clinicians alike. Innovation: This study assessed both clinicians and surrogate decision-makers' perspectives on communication and decision-making concerning care preferences, goals, and ACP. The study findings from a national cohort can inform decision-support interventions for clinicians and surrogate decision-makers of PWAD.
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BACKGROUND/OBJECTIVE: The VA MISSION Act aimed to increase Veterans' access to care by allowing eligible Veterans to use VA-paid care from non-VA providers ("VA-purchased care"). We interviewed Veterans who were eligible for both VA-delivered and VA-purchased care to examine factors they consider when making decisions about whether to use VA-delivered or VA-purchased care. METHODS: We conducted semi-structured interviews with 28 Veterans across the USA who were eligible for VA-delivered and VA-purchased care, using deductive and inductive analysis to develop themes. Participants were recruited from a survey about healthcare access and decision-making. More than half of participants lived in rural areas, 21 were men, and 25 were > 50 years old. KEY RESULTS: Veteran participants identified (1) high-quality relationships with providers based on mutual trust, empathy, authenticity, and continuity of care, and (2) a positive environment or "eco-system of care" characterized by supportive interactions with staff and other Veterans, and exemplary customer service as integral to their decisions about where to receive care. These preferences influenced their engagement with VA and non-VA providers. We discovered corresponding findings related to Veterans' information needs. When making decisions around where to receive care, participants said they would like more information about VA and non-VA providers and services, and about coordination of care and referrals, including understanding processes and implications of utilizing VA-purchased care. DISCUSSION/CONCLUSION: Current VA-purchased care eligibility determinations focus on common access metrics (e.g., wait times, distance to care). Yet, Veterans discussed other important factors for navigating care decisions, including patient-provider relationship quality and the larger healthcare environment (e.g., interactions with staff and other Veterans). Our findings point to the need for health systems to collect and provide information on these aspects of care to ensure care decisions reflect what is important to Veterans when navigating where to receive care.
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Veteranos , Masculino , Estados Unidos , Humanos , Persona de Mediana Edad , Femenino , United States Department of Veterans Affairs , Accesibilidad a los Servicios de Salud , Relaciones Profesional-Paciente , Investigación CualitativaRESUMEN
Objective: Evidence-based decision support resources do not exist for persons with lung cancer. We sought to develop and refine a treatment decision support, or conversation tool, to improve shared decision-making (SDM). Methods: We conducted a multi-site study among patients with stage I-IV non-small cell lung cancer (NSCLC) who completed or had ongoing lung cancer treatment using semi-structured, cognitive qualitative interviews to assess participant understanding of content. We used an integrated approach of deductive and inductive thematic analysis. Results: Twenty-seven patients with NSCLC participated. Participants with prior cancer experiences or those with family members with prior cancer experiences reported better preparedness for cancer treatment decision-making. All participants agreed the conversation tool would be helpful to clarify their thinking about values, comparisons, and goals of treatment, and to help patients communicate more effectively with their clinicians. Conclusion: Participants reported that the tool may empower them with confidence and agency to actively participate in cancer treatment SDM. The conversation tool was acceptable, comprehensible, and usable. Next steps will test effectiveness on patient-centered and decisional outcomes. Innovation: A personalized conversation tool using consequence tables and core SDM components is novel in that it can encourage a tailored, conversational dynamic and includes patient-centered values along with traditional decisional outcomes.
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The purpose of this experiment was to test the effect of gender on knowledge attribution using a Justified True Belief (JTB) framework. A 2 (gender: male, female) × 3 (knowledge case: knowledge control, Gettier, ignorance control) experimental design was used with a sample of 420 U.S. adults. Contrary to hypotheses, participants attributed similar levels of knowledge to male and female agents across all knowledge conditions; participants also rated males and females as equally likely to have the 'right' answer across knowledge conditions. However, knowledge was more likely to be attributed to luck (as opposed to ability) for female agents than it was for male agents across knowledge conditions and scenarios. This result suggests that while overt forms of gender bias may be fading, more covert forms still exist. Secondary analyses also showed that the JTB methodology was not robust to scenario type or knowledge condition. Comprehension was affected by both knowledge condition (knowledge vs. Gettier/ignorance) and the specific content of the hypothetical scenario presented (e.g., squirrel vs. jewelery). These confounds should be addressed in future JTB studies as it is possible that differences between knowledge and Gettier cases are due to misunderstanding the scenarios rather than beliefs about knowledge. Theoretical and practical implications of the findings are discussed.