ORIGINAL ARTICLE
Patterns of Sex and Racial/Ethnic Differences in Patient Health Care Experiences in US Veterans Affairs Hospitals Leslie R. M. Hausmann, PhD,*w Shasha Gao, PhD,* Maria K. Mor, PhD,*z James H. Schaefer, Jr, MPH,y and Michael J. Fine, MD, MSc*w
Background: Few studies have assessed sex or racial/ethnic differences in inpatient experiences in the Veterans Affairs (VA) Healthcare System. Objectives: This study aimed to compare inpatient experiences by sex and race/ethnicity within and between VA hospitals. Research Design: We used mixed-effects multinomial regression to assess within-facility and between-facility sex and racial/ethnic differences in the 2010 VA Survey of Healthcare Experiences of Patients. Subjects: 50,471 respondents from 144 VA hospitals (4.5% female; 75.4% non-Hispanic white, 14.7% non-Hispanic black, 5.4% Hispanic, and 4.4% other race/ethnicity). Measures: Negative and positive patient-reported experiences in 13 health care domains were included. Results: Adjusted within-facility sex differences indicated that women reported more negative and less positive experiences than men in 4 domains, and less negative and more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics reported less negative and/or more positive experiences than whites within the same facility, although patients at facilities with more black and Hispanic patients reported more negative and less positive experiences overall. There were few and inconsistent within-facility differences between other
From the *Veterans Affairs Pittsburgh Healthcare System, VA Center for Health Equity Research and Promotion; wDepartment of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine; zDepartment of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; and yDepartment of Veterans Affairs, Office of Informatics and Analytics, Durham, NC. Supported by the Center for Health Equity Research and Promotion (CHERP) VISN4 Pilot Research Program (LIP 72-056). L.R.M.H.’s effort was supported by the Veterans Affairs Health Services Research and Development Career Development Program (RCD 06-287). The views expressed here are those of the authors and do not represent those of the Department of Veterans Affairs or the United States Government. The authors declare no conflict of interest. Reprints: Leslie R. M. Hausmann, PhD, Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Building 30, University Drive (151C), Pittsburgh, PA 15240. E-mail: leslie. [email protected]. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.lww-medical care.com. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5204-0328
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racial/ethnic patients and whites. Patients at facilities with more other racial/ethnic patients reported slightly less negative and more positive experiences. Conclusions: Male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities. However, less positive experiences are reported by patients overall in hospitals that serve larger populations of women and racial/ethnic minorities. Key Words: sex, race and ethnicity, HCAHPS, health care experiences, veterans (Med Care 2014;52: 328–335)
T
he Veterans Affairs (VA) Healthcare System provides medical care to over 5 million United States (US) Veteran patients through a nationwide network of facilities.1 Paralleling the active-duty military, the Veteran population is rapidly changing in terms of sex, race, and ethnicity. Although only 6.0% of Veterans were female in 2000, this number rose to 9.6% in 2010 and is projected to reach 17.7% by 2040.2,3 The percentage of Veterans from racial or ethnic minority groups is expected to increase from 17.6% in 2000 to 44.3% by 2040.2,3 Given these changing demographics, it is imperative to ensure that Veterans from under-represented sex and racial/ethnic groups have equitable health care experiences at VA facilities. Few studies have examined sex differences in VA patient experiences.4,5 One national study found that female VA patients reported less positive experiences in multiple domains of inpatient health care.5 A recent non-VA study also reported consistent sex differences in a national sample of inpatients using the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS), a widely-used survey assessing inpatient experiences.6,7 Women reported less positive experiences than men on most domains, with largest differences occurring for communication about medications, discharge information, and hospital cleanliness.7 The current study examines whether similar differences occur within VA hospitals, as the VA Healthcare System recently began using HCAHPS to assess patient experiences. Racial/ethnic variation in patient experiences has been studied more thoroughly than sex variation,8–20 although little of this work has focused on the VA Healthcare System. A recent study of VA outpatients reported variation across white, black, Hispanic, and other racial/ethnic patients in both negative and positive outpatient experiences and identified that Medical Care
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differences occurred primarily within facilities for some groups and between facilities for others.21 It is unclear whether similar racial/ethnic variation occurs within and/or between VA inpatient facilities. In this study, we examine patient-reported experiences with health care in a nationally representative sample of inpatients from VA hospitals who completed the 2010 VA Survey of Healthcare Experiences of Patients (SHEP), an annual survey conducted by the VA Office of Analytics and Business Intelligence. Our goals were to: (1) compare rates of negative and positive patient experiences by sex and racial/ethnic groups; and (2) determine whether sex and racial/ethnic differences occur within and/or between VA inpatient facilities.
METHODS Patient Sample and Recruitment Procedures Patients were randomly sampled monthly from VA Medical Centers (VAMCs) from October 2009 to September 2010. Eligible patients were discharged from an acute care VAMC in the previous month; had a medical, surgical, or psychiatric Medicare Severity Diagnosis Related Group (MSDRG) code at discharge; and had not participated in a SHEP administration in the previous 12 months. Sample sizes were designed to have at least 300 completed surveys from patients with medical or surgical MSDRGs per facility in a 12-month period. Following the HCAHPS Quality Assurance Guidelines,22 a survey and cover letter were mailed to patients between 2 and 42 days after discharge. Nonresponders received a second mailing after 21 days, with the data collection period ending 21 days later. All surveys and letters were in English. For this analysis, we excluded respondents from VAMCs outside the 50 states, with a psychiatric MSDRG, or with unreported race/ethnicity. Respondents with psychiatric MSDRG diagnoses were excluded because they are not included in the HCAHPS sampling protocol or calculation of facility performance rates.22 Overall, 58,051 (43.6%) Veterans from 144 VAMCs responded to 133,148 surveys. Respondents were significantly more likely than nonrespondents to be male (95.7% vs. 94.4%), older than 55 years of age (86.1% vs. 70.9%), and in the lowest (groups 7–8) VA priority groups (12.9% vs. 9.6%). After excluding 5575 (9.6%) respondents with a psychiatric MSDRG, 1632 (2.8%) with unspecified race/ethnicity, and 373 (0.6%) from VAMCs outside the 50 states, 50,471 respondents were included in the analyses.
Patient Experiences in VA Hospitals
items measuring cleanliness of hospital environment, quietness of hospital environment, overall hospital rating, and willingness to recommend hospital. VA-specific domains included a multi-item composite measure of shared decision making and single items measuring privacy and noise level, specifically in patients’ rooms. We categorized responses into negative, moderate, and positive experiences for each domain (Appendix, Supplemental Digital Content 1, http://links.lww.com/MLR/A692).23 Consistent with previous work documenting racial/ethnic differences in extreme response tendency (ERT),24 Hispanics in our sample were more likely than whites to use the most positive and negative response categories for most outcomes. ERT was observed for few outcomes among black respondents and was not present among other racial/ethnic minority respondents or women. We selected cut-points for each outcome with the goal of having approximately 10%–15% of responses classified as negative experiences23 and to alleviate issues with ERT by including more moderately negative or positive responses in the negative and positive response categories, respectively. This resulted in the top 2 response categories being categorized as positive for all outcomes with Z5 possible response categories. For outcomes with 3 or 4 response categories, only the top category was categorized as positive.
Independent Variables Our independent variables were respondent sex and race/ ethnicity and the sex and racial/ethnic composition of patients at respondents’ VAMCs. We obtained respondent sex (male or female) from VA administrative data. We obtained respondent race/ethnicity from 2 self-reported items assessing ethnicity and race, which we used to categorize respondents into 4 racial/ ethnic groups: non-Hispanic white (ie, white), non-Hispanic black (ie, black), Hispanic, and non-Hispanic other (ie, other). The other category included groups that were too small to be analyzed separately (ie, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, and multi-racial respondents). To estimate between-facility differences, we used sex and race/ ethnicity data from VA Medical SAS inpatient and outpatient files to calculate the proportions of female patients and patients in each racial/ethnic group who had an inpatient stay at each facility during fiscal year 2010. There was no missing sex data in the administrative sample. Although data on race/ethnicity were missing for 9.8% of this administrative sample, computing the proportion in each racial/ethnic group based on the known data provided estimates very similar to those obtained using more complex missing data methods and utilizing supplemental data sources for race/ethnicity.
Measures Study Outcomes
Control Variables
Outcomes included patient-reported VA health care experiences measured in the 2010 VA SHEP. The SHEP consisted of the HCAHPS instrument6 and items assessing 3 domains of interest to VA (Appendix, Supplemental Digital Content 1, http://links.lww.com/MLR/A692). HCAHPS domains included multi-item composites measuring communication with nurses, with doctors, and about medication; responsiveness of hospital staff; discharge information; and pain management. HCAHPS domains also included single
We controlled for patient characteristics that are typically associated with patient satisfaction and are used to generate case-mix adjusted HCAPHS scores, including age, education, health status, and MSDRG.25 We also controlled for variables that predict patient experiences within the VA health care system and vary by race/ethnicity and sex, including rural versus urban residence and VA priority group. The latter conveys Veterans’ level of eligibility for VA health services, given their financial means
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and service-connected health conditions, with higher priority groups having increased eligibility. We obtained age, residence, and priority group from VA administrative data. We obtained self-reported health status and educational level from the SHEP. Although SHEP assessed primary language spoken at home (English, Spanish, or another), too few respondents spoke a language other than English (n = 820, 1.41%) to adjust for language in the analysis.
Analytic Methods We applied sampling weights to account for the sampling frame and variation in response rate by patient age and sex. All results are based on weighted data. We examined unadjusted rates of negative, moderate, and positive experiences for each domain overall and separately for sex and racial/ethnic groups. We used mixed-effects multinomial regression to examine within-facility and between-facility sex and racial/ethnic differences in negative and positive (vs. moderate) experiences for each domain, adjusting for control variables as fixed effects and facility as a random effect. Models were adjusted for patient age, health status, education, residence, priority group, and MSDRG. Estimating interactions between sex, race/ethnicity, and other demographic variables was not feasible because of relatively small numbers of women and minority respondents. We calculated within-facility and between-facility risk differences representing an adjusted absolute difference in the estimated proportion of patients reporting positive and negative health experiences for each domain. Within-facility risk differences for females were based on patient-level sex and represent the adjusted absolute difference for female patients compared with male patients at the same facility. Within-facility risk differences for each racial/ethnic group were computed in a similar manner and represent the adjusted absolute difference for patients from the specified minority group compared with white patients at the same facility. Between-facility risk differences were computed based on facility-level terms for the proportion of patients belonging to each sex and racial/ethnic group. Betweenfacility risk differences for female patients represent the adjusted absolute difference in the estimated proportion of patients reporting positive or negative health experiences, comparing facilities with a female composition typical of those visited by female patients (5.4%) and facilities with a female composition typical of those visited by male patients (5.2%). Between-facility risk differences for each racial/ ethnic group were computed in a similar manner with a similar interpretation. For example, given that the median proportions of black patients are 33.5% and 14.1% for facilities attended by black respondents and white respondents, respectively, the black between-facility risk difference for positive experiences represents the difference in proportion of patients reporting positive experiences at facilities with 33.5% versus 14.1% black patients. We estimated 95% confidence intervals (CIs) for all risk differences (RDs) using bootstrap methods.26,27 We defined statistical significance using 2-sided tests at the 0.05 level. We used SAS 9.3 (SAS Institute Inc., Cary, NC) software for all analyses.
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RESULTS Respondent Characteristics Of the 50,471 respondents included in the analysis, 1967 (4.5%) were female; 39,725 (75.4%) were white; 6319 (14.7%) were black; 2326 (5.4%) were Hispanic; and 2101 (4.4%) were other race/ethnicity (Table 1). Most respondents were in the older age groups (55–64 y: 37.2%; 65–74 y: 21.9%; 75 y or older: 25.9%), were urban residents (57.5%), and had either a high school diploma (36.0%) or completed some college (34.2%). Significant sex and racial/ethnic differences existed for all patient characteristics (Table 1). Compared with men, women were more frequently racial/ethnic minorities, younger, in better health, more educated, urban residents, and in higher priority groups. Compared with whites, racial/ethnic minorities were more frequently female, younger, urban residents, and in higher priority groups.
Sex Differences in Inpatient Health Care Experiences In unadjusted analyses, women reported significantly more negative and less positive experiences than men in 10 domains (Table 2). For 3 domains (quietness of hospital, noise level in room, and privacy in room), women reported more positive health care experiences (Table 2). Adjusted analyses identified significant within-facility sex differences in negative experiences, with women reporting more negative experiences than men on 4 domains (RD range: 1.83% for discharge information to 5.83% for shared decision making) and less negative experiences on 1 domain (privacy in room; RD = 7.10%; 95% CI: 8.88%, 5.24%) (Table 3). Significant between-facility sex differences indicated more negative experiences at facilities with more female patients for 4 domains (RD range: 0.07% for overall hospital rating to 0.20% for privacy in room). Significant within-facility sex differences in positive experiences indicated that women reported less positive experiences than men for 4 domains (RD range: 4.26% for cleanliness of hospital environment to 8.46% for communication about medication) and more positive experiences for 3 domains (RD range: 4.07% for quietness of hospital environment to 13.21% for privacy in room). Between-facility sex differences indicated significantly less positive experiences at facilities with more female patients for 4 domains (RD range: 0.07% for overall rating of hospital to 0.19% for privacy in room).
Racial/Ethnic Differences in Patient Health Care Experiences In unadjusted analyses (Table 2), blacks reported more negative and less positive experiences than whites for 7 and 6 domains, respectively. However, for 5 domains, blacks reported more positive and less negative experiences. Hispanics reported significantly more negative experiences than whites for 9 domains (ranging from 0.40% to 2.20%). In contrast, Hispanics reported significantly more positive experiences for 10 domains, with differences ranging from 0.10% to 5.70%. Other racial/ethnic respondents reported significantly more negative experiences than whites for all domains and less r
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r
Total Sample (n = 50,471)
2014 Lippincott Williams & Wilkins 8.7 25.6 36.9 21.9 7.0 66.1 33.9 64.6 35.4 49.4 4.9 32.6 0.7 12.4
13.5 34.5 33.8 16.7 4.6 72.1 27.9 57.2 42.8 39.7 6.2 38.8 2.2 13.1
5.4 (4.8, 6.3)
(60.7, 83.2) (9.0, 32.1) (0.8, 6.3) (1.3, 2.5)
0.2 1.3 18.6 53.3 13.7 12.9
6.2 10.9 36.8 33.3 6.8 6.0
76.5 16.6 2.1 1.9
10.0 12.8 26.6 29.7 9.8 11.1
1.2 2.2 10.1 37.5 22.4 26.6
(62.2, 86.2) (8.6, 29.7) (0.8, 5.1) (1.3, 2.4)
66.3 20.3 5.0 8.4
(67.6, 89.0) (7.9, 22.8) (0.8, 4.4) (1.3, 2.4) 5.2 (4.4, 6.0)
80.0 14.1 1.5 1.8
39.5 5.7 38.2 2.3 14.3
51.6 48.4
71.4 28.6
14.1 31.2 33.7 16.6 4.4
6.1 10.3 36.9 32.9 7.2 6.6
1.4 2.1 8.8 36.3 23.4 28.1
3.9
White (n = 39,725)
5.3 (4.6, 6.3)
61.0 (46.7, 75.6) 33.5 (17.8, 42.9) 1.4 (0.8, 4.7) 1.5 (1.1, 1.9)
40.0 7.8 41.5 1.3 9.4
81.0 19.0
74.9 25.1
9.7 32.2 34.3 17.8 5.5
5.2 11.3 34.7 38.1 5.8 4.9
1.5 4.2 19.2 39.7 16.3 19.2
6.2
Black (n = 6319)
(56.2, 78.6) (9.3, 29.7) (3.5, 14.6) (1.7, 3.7) 5.5 (4.9. 6.3)
67.6 13.9 10.2 2.2
42.1 7.4 38.0 2.6 9.9
74.8 25.2
71.0 29.1
11.4 28.9 33.5 19.1 7.1
6.8 11.3 33.4 36.9 7.3 4.4
3.8 4.9 13.3 38.6 18.1 21.3
4.2
Hispanic (n = 2326)
(62.6, 84.9) (9.0, 29.7) (0.8, 6.3) (1.4, 3.4) 5.3 (4.7, 6.0)
77.0 15.0 2.0 2.0
49.8 6.5 34.7 1.0 8.0
57.8 42.2
13.2 31.1 33.7 17.3 4.7
3.8 8.6 28.1 41.4 9.0 9.2
3.4 3.6 13.7 42.7 19.7 17.0
8.6
Otherw (n = 2101)
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5.2 (4.4, 6.0)
78.6 15.1 1.6 1.8
Female (n = 1967)
75.9 14.5 5.5 4.2
Male (n = 48,504)
*All statistics were calculated using weighted data. Differences between males and females and between racial/ethnic groups were tested using w2 tests for categorical variables and t tests or analysis of variance for continuous variables. All differences were statistically significant (P < 0.0001). w Other category included respondents from the following racial/ethnic groups: Native Hawaiian/Pacific Islander (n = 85), Asian (n = 146), American Indian/Alaska Native (n = 562), and multi-racial (n = 1308). HS indicates high school; IQR, interquartile range; MSDRG, Medicare Severity Diagnosis Related Group code at discharge; y, year.
Race/ethnicity (%) White 75.4 Black 14.7 Hispanic 5.4 Other 4.4 Female sex (%) 4.5 Age (%) (y) 18–34 1.6 35–44 2.7 45–54 10.8 55–64 37.2 65–74 21.9 75 or older 25.9 Educational level (%) r8th grade 5.9 Some HS 10.5 HS diploma 36.0 Some college 34.2 4 y degree 7.1 Z4 y degree 6.4 Health status (%) Poor 13.2 Fair 31.2 Good 33.9 Very good 17.0 Excellent 4.7 Discharge MSDRG Medical 71.8 Surgical 28.2 Residential status (%) Urban 57.5 Rural 42.5 VA priority group (%) 1–3 (highest priority) 40.1 4 6.2 5 38.5 6 2.1 7–8 (lowest priority) 13.1 Patient racial/ethnic composition of facility [median (IQR)] % White 78.6 (62.2, 86.2) % Black 15.1 (8.6, 29.7) % Hispanic 1.7 (0.8, 5.1) % Other 1.8 (1.3, 2.4) Patient sex composition of facility [median (IQR)] % Female 5.2 (4.5, 6.0)
Characteristics
TABLE 1. Baseline Characteristics of Respondents by Sex and Race/Ethnicity*
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TABLE 2. Unadjusted Rates of Negative () and Positive (+) Inpatient Health Care Experiences Stratified by Sex and Race/Ethnicity* % Total Dimension of Care (No. Respondents) Communication with nurses (n = 50,430) Communication with doctors (n = 50,429) Communication about medication (n = 28,062) Responsiveness of hospital staff (n = 39,692) Discharge information (n = 43,845) Pain management (n = 32,370) Cleanliness of hospital environment (n = 50,031) Quietness of hospital environment (n = 49,417) Overall rating of hospital (n = 49,459) Willingness to recommend hospital (n = 49,806) Shared decision making (n = 48,275) Privacy in room (n = 48,442) Noise level in room (n = 48,656)
Male
Female
White
Black
Hispanic
Other
+
+
+
+
+
+
+
10.2 9.7 16.3 11.5 7.9 12.7 9.2 16.1 10.9 6.4 23.3 16.1 20.3
70.2 73.3 61.2 59.6 73.2 68.5 70.2 48.1 63.9 68.2 62.4 62.4 56.3
10.1 9.6 16.1 11.4 7.8 12.5 8.8 16.1 10.7 6.3 23.0 16.2 20.3
70.2 73.4 61.7 59.7 73.5 68.6 70.6 47.9 64.4 68.6 62.7 61.9 56.1
12.6 13.3 22.1 14.5 10.5 16.1 16.4 17.1 15.7 9.5 29.4 12.3 20.6
68.7 70.0 52.4 56.8 66.8 67.7 63.1 52.9 53.9 60.5 57.7 72.2 60.8
9.9 9.9 16.6 10.7 7.7 12.3 8.7 16.8 10.4 6.1 23.2 16.3 21.0
69.4 72.6 60.7 59.8 73.6 68.5 70.5 45.2 64.3 69.4 63.0 62.0 55.2
10.8 8.7 15.0 15.0 8.6 13.4 10.6 10.8 11.9 7.2 22.9 14.5 15.2
73.4 75.9 62.7 57.2 71.6 68.6 69.7 62.3 61.4 62.7 59.7 64.2 62.9
10.7 8.6 14.4 12.5 8.1 12.9 11.1 18.5 11.3 6.5 21.9 16.0 23.2
73.7 78.3 66.4 63.6 73.5 71.1 69.3 50.7 69.1 69.3 65.2 63.7 55.3
12.3 11.6 18.2 12.9 9.0 15.8 9.9 18.4 15.5 9.0 27.7 17.7 21.8
68.2 70.1 58.9 59.5 71.4 64.8 68.1 49.0 60.4 65.0 58.3 60.9 56.1
*All rates were calculated using weighted data. All pairwise comparisons between non-Hispanic white and each racial/ethnic minority group were statistically significant at Pr0.001. All pairwise comparisons between males and females were statistically significant at Pr0.001.
positive experiences than whites for 11 domains, with differences ranging from 0.30% to 5.10%. Adjusted analyses identified significant within-facility differences in negative experiences between blacks and whites for 7 domains, with blacks reporting less negative experiences (RD range: 1.49% for communication with doctors to 7.22% for quietness of hospital environment) (Table 3). However, between-facility differences indicated significantly more negative experiences reported by respondents at facilities with more black patients for 9 domains (RD range: 1.12% for discharge information to 4.46% for responsiveness of hospital staff). Within-facility analyses also revealed that blacks reported significantly more positive experiences for 7 domains (RD range: 1.90% for responsiveness of hospital staff to 16.26% for quietness of hospital environment) and less positive experiences for willingness to recommend the hospital (RD = 1.92%; 95% CI: 3.73%, 0.01%). Betweenfacility differences indicated significantly less positive experiences reported by respondents at facilities with more black patients for 10 domains (RD range: 1.71% for privacy in room to 5.25% for responsiveness of hospital staff) but significantly more positive experiences with quietness of hospital environment reported at facilities with more black patients (RD = 2.76%; 95% CI: 1.81%, 3.59%). Adjusted analyses identified 2 significant withinfacility differences in negative experiences for Hispanics, who reported less negative experiences than whites with communication about medication (RD = 3.85%; 95% CI: 5.97%, 1.49%) and privacy in room (RD = 1.83%; 95% CI: 3.80%, 0.10%). In contrast, between-facility analyses indicated significantly more negative experiences reported at facilities with more Hispanic patients for 9 domains (RD range: 0.57% for overall rating of hospital to 2.34% for responsiveness of hospital staff). Within-facility analyses indicated that Hispanics reported more positive experiences than whites for 9 domains (RD range: 2.73% for privacy in room to 7.57% for responsiveness of hospital staff). Between-facility analyses indicated significantly less
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positive experiences reported at facilities with more Hispanic patients for 7 domains (RD range: 1.11% for discharge information to 2.14% for responsiveness of hospital staff). Adjusted analyses identified 3 significant within-facility differences in negative experiences for other race/ethnicity respondents, who reported more negative experiences than whites (RD range: 1.97% for willingness to recommend hospital to 3.64% for shared decision making). There were also small, statistically significant between-facility differences indicating less negative experiences reported at facilities with more other racial/ethnic patients in 5 domains (RD range: 0.09% for overall rating of hospital to 0.25% for privacy in room). Within-facility analyses also indicated that other race/ethnicity respondents reported more positive experiences than whites for quietness of hospital (RD = 4.66%; 95% CI: 1.78%, 7.42%) and less positive experiences for shared decision making (RD = 4.10%; 95% CI: 7.06%, 1.41%). Between-facility analyses indicated significantly more positive experiences reported at facilities with more other race/ethnicity patients for 6 domains (RD range: 0.14% for willingness to recommend hospital to 0.27% for privacy in room).
DISCUSSION We found significant within-facility and betweenfacility sex and racial/ethnic differences in patient-reported experiences in multiple domains in a nationally representative sample of VA inpatients. In adjusted, within-facility analyses, women tended to report more negative and/or less positive experiences than men, although women did report more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics tended to report less negative and/or more positive experiences than whites within the same facility, although patients at facilities with higher proportions of black and Hispanic patients reported more negative and less positive experiences overall. There were r
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Patient Experiences in VA Hospitals
TABLE 3. Adjusted Within-Facility and Between-Facility Risk Differences in Negative and Positive Inpatient Health Care Experiences for Sex and Racial/Ethnic Groups Negative Patient Experiences Dimension of Care For Sex and Racial/Ethnic Groups Communication with nurses Black Hispanic Other Female Communication with doctors Black Hispanic Other Female Communication about medication Black Hispanic Other Female Responsiveness of hospital staff Black Hispanic Other Female Discharge information Black Hispanic Other Female Pain management Black Hispanic Other Female Cleanliness of hospital environment Black Hispanic Other Female Quietness of hospital environment Black Hispanic Other Female Overall rating of hospital Black Hispanic Other Female Willingness to recommend hospital Black Hispanic Other Female Shared decision making Black Hispanic Other Female Privacy in room Black Hispanic Other Female
Within-facility
w
Positive Patient Experiences
Between-facility
z
RD
95% CI
RD
95% CI
1.49* 0.65 1.06 0.70
2.61, 0.42 2.33, 1.26 0.86, 3.01 1.06, 2.38
2.84* 1.13* 0.02 0.03
2.37, 3.60 0.63, 1.65 0.10, 0.05 0.02, 0.09
1.53* 1.63 1.03 1.53
2.60, 0.41 3.19, 0.15 0.68, 3.03 0.03, 3.58
0.13 0.09 0.03 0.00
0.54, 0.34, 0.11, 0.04,
3.58* 3.85* 0.36 4.70*
5.28, 2.00 5.97, 1.49 2.74, 4.00 2.03, 7.94
2.48* 0.66 0.14* 0.01
1.92 1.28 3.02 2.17
Within-facilityw 95% CI
RD
95% CI
7.09* 6.30* 0.66 0.76
5.50, 8.66 3.82, 8.85 2.40, 3.60 2.14, 3.51
2.95* 1.52* 0.05 0.03
3.89, 2.29 2.24, 0.89 0.18, 0.06 0.11, 0.03
3.88* 6.16* 1.60 2.11
2.48, 5.68 3.75, 8.37 4.24, 1.04 5.28, 0.72
0.82 0.00 0.05 0.02
1.66, 3.36 0.23, 1.31 0.29, 0.01 0.07, 0.07
4.67* 6.90* 0.56 8.46*
2.30, 6.92 2.97, 11.05 4.09, 3.35 12.96, 4.70
3.36* 0.51 0.17* 0.03
4.38, 2.26 1.48, 0.48 0.00, 0.35 0.06, 0.14
4.46* 2.34* 0.12* 0.03
3.87, 5.50 1.78, 2.97 0.24, 0.03 0.03, 0.09
1.90* 7.57* 1.94 0.96
0.18, 3.95 4.97, 10.60 1.42, 5.14 2.94, 3.99
5.25* 2.14* 0.00 0.02
6.36, 4.50 3.02, 1.28 0.16, 0.13 0.07, 0.11
1.00, 1.10 1.04, 2.37 0.90, 2.80 0.05, 3.76
1.12* 0.48 0.04 0.02
0.65, 1.59 0.04, 1.00 0.12, 0.02 0.02, 0.07
0.24 0.16 1.38 6.43*
1.83, 1.68 2.37, 2.85 3.87, 1.34 9.49, 3.39
2.49* 1.11* 0.05 0.01
3.47, 1.76 1.92, 0.47 0.16, 0.07 0.09, 0.07
1.06 0.86 1.84 0.30
2.43, 3.07, 0.71, 2.53,
0.60 1.38 4.26 2.03
1.88* 0.95* 0.12 0.02
1.32, 2.78 0.27, 1.71 0.24, 0.01 0.04, 0.09
3.24* 4.72* 1.93 2.86
1.29, 5.32 1.78, 7.87 5.34, 1.37 0.41, 5.81
2.73* 1.34* 0.13 0.00
3.90, 1.93 2.24, 0.29 0.03, 0.26 0.09, 0.08
0.70 1.18 0.19 5.31*
1.78, 0.33 0.46, 2.90 1.60, 2.23 3.25, 7.47
2.92* 1.02* 0.06 0.03
2.43, 3.69 0.56, 1.59 0.18, 0.01 0.03, 0.09
2.07* 0.28 1.13 4.26*
0.22, 3.83 2.16, 2.73 3.84, 1.69 7.18, 1.29
3.84* 1.56* 0.19* 0.02
4.71, 3.03 2.35, 0.89 0.08, 0.34 0.10, 0.07
7.22* 0.20 1.23 0.37
8.41, 5.91 1.82, 2.18 1.26, 3.52 2.51, 2.11
0.28 1.46* 0.05 0.12*
0.41, 0.95 0.90, 2.01 0.15, 0.04 0.06, 0.20
16.26* 5.89* 4.66* 4.07*
18.14 8.81 7.42 7.03
2.76* 0.82 0.12 0.10*
1.81, 3.59 1.64, 0.01 0.00, 0.27 0.20, 0.02
0.57 0.30 3.36* 1.42
1.83, 0.45 2.19, 1.66 1.39, 5.66 0.59, 3.34
2.27* 0.57* 0.09* 0.07*
1.53 7.19* 1.45 2.94
0.30, 3.28 4.88, 9.72 4.48, 1.21 6.61, 0.38
3.71* 0.03 0.16* 0.07*
4.69, 2.98 0.90, 0.68 0.04, 0.27 0.16, 0.00
0.14 0.45 1.97* 0.07
1.10, 0.91 1.79, 1.02 0.13, 3.64 1.34, 1.54
1.16* 0.29 0.06 0.03
0.67, 1.70 0.09, 0.72 0.13, 0.01 0.00, 0.08
1.92* 1.55 2.24 2.74
3.73, 0.01 0.93, 4.38 4.85, 0.87 6.15, 0.27
4.85* 0.04 0.14* 0.03
5.72, 3.95 0.77, 0.68 0.01, 0.25 0.11, 0.04
2.01* 1.69 3.64* 5.83*
3.55, 0.59 4.05, 0.91 1.14, 6.07 2.75, 8.71
1.69* 0.66* 0.09 0.02
1.09, 2.65 0.01, 1.34 0.19, 0.03 0.05, 0.09
1.57 2.82* 4.10* 4.87*
3.33, 0.49 0.19, 5.57 7.06, 1.41 8.17, 1.95
2.68* 0.61 0.08 0.04
3.66, 1.99 1.41, 0.11 0.05, 0.20 0.12, 0.05
1.98* 1.83* 0.52 7.10*
3.42, 0.72 3.80, 0.10 1.88, 3.06 8.88, 5.24
0.68 1.11* 0.25* 0.20*
0.17, 1.43 0.39, 1.78 0.38, 0.15 0.12, 0.30
1.61 2.73* 0.31 13.21*
0.07, 3.42 0.18, 5.53 3.11, 2.67 10.38, 15.79
1.71* 1.65* 0.27* 0.19*
2.58, 2.50, 0.13, 0.29,
0.61 0.61 0.73 0.09 0.11 0.55 0.86 1.83*
0.68, 2.29, 1.34, 2.26,
1.74, 0.13, 0.18, 0.02,
0.50 0.55 0.05 0.06
3.05 1.10 0.01 0.13
RD
Between-facilityz
14.58, 3.28, 1.78, 0.87,
0.05, 0.64, 0.07, 0.10,
1.50 0.69 0.17 0.05
0.76 0.85 0.42 0.08
(Continued )
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TABLE 3. Adjusted Within-Facility and Between-Facility Risk Differences in Negative and Positive Inpatient Health Care Experiences for Sex and Racial/Ethnic Groups (continued) Negative Patient Experiences Dimension of Care For Sex and Racial/Ethnic Groups Noise level in room Black Hispanic Other Female
Within-facility
w
Positive Patient Experiences
Between-facility
z
RD
95% CI
RD
95% CI
6.37* 0.84 0.08 2.25
8.06, 5.01 1.57, 3.09 2.13, 2.79 4.80, 0.41
0.16 1.49* 0.12* 0.13*
0.58, 0.93 0.83, 2.19 0.27, 0.03 0.06, 0.20
Within-facilityw RD 7.99* 1.54 2.14 6.62*
Between-facilityz
95% CI
RD
95% CI
6.28, 9.75 1.12, 4.56 1.21, 5.31 3.47, 9.28
0.05 1.60* 0.23* 0.18*
0.98, 0.94 2.39, 0.83 0.13, 0.39 0.28, 0.10
Models adjusted for patient age, education, health status, medical or surgical Medicare Severity Diagnosis Related Group code at discharge, rural versus urban residence, and VA priority group. *P < 0.05. RD > 0 for negative experiences and RD < 0 for positive experiences indicate less positive experiences for female (vs. male) and racial/ethnic minority (vs. white) patients. Significant differences reflecting less positive experiences for female or racial/ethnic minority patients are in bold. w Within-facility risk differences for females represent the adjusted absolute difference for female patients compared with male patients. Within-facility risk differences for each racial/ethnic group represent the adjusted absolute difference for patients from the specified minority group compared with non-Hispanic white patients. z Between-facility risk differences for females represent the adjusted absolute difference in the estimated proportion of patients reporting negative or positive health experiences comparing facilities with a female composition typical of those visited by female patients (proportion of female patients at the facility set to the median value for female respondents) to facilities with a female composition typical of those visited by male patients. Between-facility risk differences for each racial/ethnic group represent the adjusted absolute difference in the estimated proportion of patients reporting negative or positive health experiences comparing facilities with a minority composition typical of those visited by the specified minority group (proportion of patients from that minority group at the facility set to the median for respondents of that racial/ethnic minority group) to facilities with a minority composition typical of those visited by non-Hispanic white patients. CI indicates confidence interval; RD, risk difference.
few and inconsistent within-facility differences between other racial/ethnic patients and whites, and slightly less negative and more positive experiences at facilities with more other racial/ethnic patients. Some of the observed sex differences are similar to those found among inpatients from non-VA hospitals, where men have reported more positive experiences for communication about medications, discharge information, and hospital cleanliness.7 However, women in our sample also reported more positive experiences on quietness of the hospital, privacy of room, and noise level of room. This may be due to efforts in VA facilities to protect the privacy of women inpatients that might result in women having a private room more often than men. Some racial/ethnic differences observed in this study are similar to those reported in previous studies. The more positive experiences reported by black and Hispanic patients compared with white patients within the same facilities are consistent with work outside VA in which blacks and Hispanics report similar, and in some cases more positive, health care experiences than whites.8–10,14,16,17,19 Less positive experiences at inpatient institutions serving more black and Hispanic patients have also been observed in VA outpatients, non-VA inpatients, and Medicaid managed-care populations.10,18,21 However, the within-facility differences we observed showing more positive experiences for black and Hispanic inpatients were of greater magnitude and for more health care domains than in a similar study of VA outpatients.21 These differences could be because of differences in the patient mix in VA outpatient and inpatient settings, as inpatients tend to be older, have poorer health status, and are being treated for more serious conditions. The inpatient survey is also tied to a specific hospitalization, whereas the outpatient survey assesses all experiences with VA care received over the last 12 months. Further, among VA outpatients and in most non-VA samples, patients from racial/ethnic minority
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groups other than black and Hispanic generally report worse health care experiences than whites.9–14,18,19,21 In our sample, however, there were few and inconsistent within-facility differences between other racial/ethnic patients and whites, and there were very small between-facility differences. The unexpected pattern for this group could be because of its relatively small sample size (n = 2101) or its heterogenous composition. It included Asians (7%), Native Hawaiian/Pacific Islanders (4%), American Indian/Alaska Natives (27%), and multi-racial patients (73% of whom were American Indian/Alaska Native and at least one other race), whereas other studies examined Asians and American Indian/Alaska Natives separately.9–13,18 Our findings have implications for future initiatives to ensure equitable health care experiences across sex and racial/ethnic groups in VA inpatient facilities. Efforts to address sex differences should target specific domains in which women report less positive experiences than men, including communication about medications, cleanliness of hospital, and use of shared decision making. Given that men reported significantly less positive experiences with privacy and noise, VA may also need to take steps to improve noise levels and provide privacy equitably for both men and women receiving inpatient care. Our findings suggest that efforts to ensure equitable experiences across racial/ethnic groups should focus on VA inpatient facilities serving higher proportions of black and Hispanic patients. Our study also has implications for assessing and reporting sex and racial/ethnic differences in VA inpatient experiences. First, women and minority patients, especially those in the other racial/ethnic group, need to be over-sampled in VA surveys to estimate differences for these groups and to examine interactions between patient sex, race/ethnicity, and other characteristics. Our findings also underscore the importance of distinguishing within-facility from between-facility effects when assessing and reporting sex r
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and racial/ethnic differences in VA inpatient experiences. Given that within-facility and between-facility differences often are in opposite directions within a given health care domain, assessing overall patient health care experiences may obscure the true magnitude of sex and racial/ethnic differences. We acknowledge that this study has limitations. First, the study sampling frame for administering HCAHPS surveys22 did not account for respondent race or ethnicity, so we could not assess racial/ethnic differences in response rates. Second, the racial/ethnic and sex composition of our sample did not allow us to examine experiences separately for Asian American/Pacific Islanders, Native Americans/Alaska Natives, and multi-racial patients, or to test interactions between race/ethnicity, sex, and other patient characteristics. The heterogeneity of the other racial/ethnic group makes it difficult to make generalizations about the health care experiences of this group. The restricted range in proportions of women and other racial/ ethnic minority patients across facilities also limits our ability to detect between-facility effects of sex and for the other racial/ ethnic group. Third, our 44% response rate may have led to biases in our study sample. Fourth, the within-facility differences showing more positive experiences for black and Hispanic respondents could be partly due to ERT among these groups,17,24 although we attempted to reduce the impact of ERT in our construction of negative, moderate, and positive response categories. Finally, it is unclear whether the observed self-reported differences were because of patient preferences, expectations, or actual differences in patient experiences. In summary, our national study of sex and racial/ethnic differences in experiences of VA inpatients demonstrates that male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities, whereas health care experiences are less positive overall in hospitals that serve more female, black, and Hispanic patients. Our findings have important implications for assessing sex and racial/ethnic differences in patient experiences in the VA Healthcare System. It also helps identify targets for interventions to reduce sex and racial/ethnic differences in health care experiences by focusing efforts on specific domains and by targeting efforts at facilities with larger female, black, or Hispanic patient populations. REFERENCES 1. National Center for Veterans Analysis and Statistics. FY 10 Summary of Expenditures by State. Available at: http://www.va.gov/vetdata/docs/ GDX/GDX_FY10_V1_41.xlsx. Accessed February 9, 2012. 2. National Center for Veterans Analysis and Statistics. Table 5L: Veterans 2000-2036 by race/ethnicity, gender, period, age. Available at: http://www1. va.gov/VETDATA/docs/Demographics/5l.xls. Accessed March 15, 2013. 3. National Center for Veterans Analysis and Statistics. Table 3L: VETPOP2011 living veterans by race/ethnicity, gender, 2010-2040. Available at: https://www.va.gov/VETDATA/docs/Demographics/ New_Vetpop_Model/3lVetPop11_Race_National.xlsx. Accessed March 15, 2013. 4. Kressin NR, Skinner K, Sullivan L, et al. Patient satisfaction with Department of Veterans Affairs health care: do women differ from men? Mil Med. 1999;164:283–288.
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5. Wright SM, Craig T, Campbell S, et al. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med. 2006;21(suppl 3):S26–S32. 6. HCAHPS Survey. Centers for Medicare & Medicaid Services. Available at: http://www.hcahpsonline.org/Files/1HCAHPS%20V7%200%20 Appendix%20 A%20-%20HCAHPS%20STANDARD%20Mail%20 Survey%20Materials%20%28English%29%20March%202012.pdf. Accessed January 23, 2013. 7. Elliott MN, Lehrman WG, Beckett MK, et al. Gender differences in patients’ perceptions of inpatient care. Health Serv Res. 2012;47:1482–1501. 8. Hunt KA, Gaba A, Lavizzo-Mourey R. Racial and ethnic disparities and perceptions of health care: does health plan type matter? Health Serv Res. 2005;40:551–576. 9. Weech-Maldonado R, Morales LS, Elliott M, et al. Race/ethnicity, language, and patients’ assessments of care in Medicaid managed care. Health Serv Res. 2003;38:789–808. 10. Weech-Maldonado R, Elliott MN, Morales LS, et al. Health plan effects on patient assessments of Medicaid managed care among racial/ethnic minorities. J Gen Intern Med. 2004;19:136–145. 11. Haviland MG, Morales LS, Dial TH, et al. Race/ethnicity, socioeconomic status, and satisfaction with health care. Am J Med Qual. 2005;20:195–203. 12. Morales LS, Elliott MN, Weech-Maldonado R, et al. Differences in CAHPS adult survey reports and ratings by race and ethnicity: an analysis of the National CAHPS benchmarking data 1.0. Health Serv Res. 2001;36:595–617. 13. Haviland MG, Morales LS, Reise SP, et al. Do health care ratings differ by race or ethnicity? Jt Comm J Qual Saf. 2003;29:134–145. 14. Lurie N, Zhan C, Sangl J, et al. Variation in racial and ethnic differences in consumer assessments of health care. Am J Manag Care. 2003;9: 502–509. 15. Merrill RM, Allen EW. Racial and ethnic disparities in satisfaction with doctors and health providers in the United States. Ethn Dis. 2003; 13:492–498. 16. Bagchi AD, Schone E, Higgins P, et al. Racial and ethnic health disparities in TRICARE. J Natl Med Assoc. 2009;101:663–670. 17. Dayton E, Zhan C, Sangl J, et al. Racial and ethnic differences in patient assessments of interactions with providers: disparities or measurement biases? Am J Med Qual. 2006;21:109–114. 18. Goldstein E, Elliott MN, Lehrman WG, et al. Racial/ethnic differences in patients’ perceptions of inpatient care using the HCAHPS survey. Med Care Res Rev. 2010;67:74–92. 19. Shi L, Macinko J. Changes in medical care experiences of racial and ethnic groups in the United States, 1996-2002. Int J Health Serv. 2008;38:653–670. 20. Rodriguez HP, von Glahn T, Grembowski DE, et al. Physician effects on racial and ethnic disparities in patients’ experiences of primary care. J Gen Intern Med. 2008;23:1666–1672. 21. Hausmann LRM, Gao S, Mor MK, et al. Understanding racial and ethnic differences in patient experiences with outpatient care in U.S. Veterans Affairs Medical Centers. Med Care. 2013;51:532–539. 22. CAHPSs Hospital Survey (HCAHPS) Quality Assurance Guidelines Version 7.0. Centers for Medicare & Medicaid Services. Available at: http://www.hcahpsonline.org/files/HCAHPS%20Quality%20Assurance %20Guidelines%20V7.0%20March%202012.pdf. Accessed January 23, 2013. 23. Elliott MN, Beckett MK, Kanouse DE, et al. Problem-oriented reporting of CAHPS consumer evaluations of health care. Med Care Res Rev. 2007;64:600–614. 24. Weech-Maldonado R, Elliott MN, Oluwole A, et al. Survey response style and differential use of CAHPS rating scales by Hispanics. Med Care. 2008;46:963–968. 25. O’Malley AJ, Zaslavsky AM, Elliott MN, et al. Case-mix adjustment of the CAHPS Hospital Survey. Health Serv Res. 2005;40:2162–2181. 26. Austin PC. Absolute risk reductions, relative risks, relative risk reductions, and numbers needed to treat can be obtained from a logistic regression model. J Clin Epidemiol. 2009;63:2–6. 27. Efron B, Tibshirani RJ. An Introduction to the Bootstrap. Boca Raton, FL: Chapman & Hall/CRC; 1993.
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Patterns of Sex and Racial/Ethnic Differences in Patient Health Care Experiences in US Veterans Affairs Hospitals Leslie R. M. Hausmann, PhD,*w Shasha Gao, PhD,* Maria K. Mor, PhD,*z James H. Schaefer, Jr, MPH,y and Michael J. Fine, MD, MSc*w
Background: Few studies have assessed sex or racial/ethnic differences in inpatient experiences in the Veterans Affairs (VA) Healthcare System. Objectives: This study aimed to compare inpatient experiences by sex and race/ethnicity within and between VA hospitals. Research Design: We used mixed-effects multinomial regression to assess within-facility and between-facility sex and racial/ethnic differences in the 2010 VA Survey of Healthcare Experiences of Patients. Subjects: 50,471 respondents from 144 VA hospitals (4.5% female; 75.4% non-Hispanic white, 14.7% non-Hispanic black, 5.4% Hispanic, and 4.4% other race/ethnicity). Measures: Negative and positive patient-reported experiences in 13 health care domains were included. Results: Adjusted within-facility sex differences indicated that women reported more negative and less positive experiences than men in 4 domains, and less negative and more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics reported less negative and/or more positive experiences than whites within the same facility, although patients at facilities with more black and Hispanic patients reported more negative and less positive experiences overall. There were few and inconsistent within-facility differences between other
From the *Veterans Affairs Pittsburgh Healthcare System, VA Center for Health Equity Research and Promotion; wDepartment of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine; zDepartment of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; and yDepartment of Veterans Affairs, Office of Informatics and Analytics, Durham, NC. Supported by the Center for Health Equity Research and Promotion (CHERP) VISN4 Pilot Research Program (LIP 72-056). L.R.M.H.’s effort was supported by the Veterans Affairs Health Services Research and Development Career Development Program (RCD 06-287). The views expressed here are those of the authors and do not represent those of the Department of Veterans Affairs or the United States Government. The authors declare no conflict of interest. Reprints: Leslie R. M. Hausmann, PhD, Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Building 30, University Drive (151C), Pittsburgh, PA 15240. E-mail: leslie. [email protected]. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.lww-medical care.com. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5204-0328
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racial/ethnic patients and whites. Patients at facilities with more other racial/ethnic patients reported slightly less negative and more positive experiences. Conclusions: Male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities. However, less positive experiences are reported by patients overall in hospitals that serve larger populations of women and racial/ethnic minorities. Key Words: sex, race and ethnicity, HCAHPS, health care experiences, veterans (Med Care 2014;52: 328–335)
T
he Veterans Affairs (VA) Healthcare System provides medical care to over 5 million United States (US) Veteran patients through a nationwide network of facilities.1 Paralleling the active-duty military, the Veteran population is rapidly changing in terms of sex, race, and ethnicity. Although only 6.0% of Veterans were female in 2000, this number rose to 9.6% in 2010 and is projected to reach 17.7% by 2040.2,3 The percentage of Veterans from racial or ethnic minority groups is expected to increase from 17.6% in 2000 to 44.3% by 2040.2,3 Given these changing demographics, it is imperative to ensure that Veterans from under-represented sex and racial/ethnic groups have equitable health care experiences at VA facilities. Few studies have examined sex differences in VA patient experiences.4,5 One national study found that female VA patients reported less positive experiences in multiple domains of inpatient health care.5 A recent non-VA study also reported consistent sex differences in a national sample of inpatients using the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS), a widely-used survey assessing inpatient experiences.6,7 Women reported less positive experiences than men on most domains, with largest differences occurring for communication about medications, discharge information, and hospital cleanliness.7 The current study examines whether similar differences occur within VA hospitals, as the VA Healthcare System recently began using HCAHPS to assess patient experiences. Racial/ethnic variation in patient experiences has been studied more thoroughly than sex variation,8–20 although little of this work has focused on the VA Healthcare System. A recent study of VA outpatients reported variation across white, black, Hispanic, and other racial/ethnic patients in both negative and positive outpatient experiences and identified that Medical Care
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differences occurred primarily within facilities for some groups and between facilities for others.21 It is unclear whether similar racial/ethnic variation occurs within and/or between VA inpatient facilities. In this study, we examine patient-reported experiences with health care in a nationally representative sample of inpatients from VA hospitals who completed the 2010 VA Survey of Healthcare Experiences of Patients (SHEP), an annual survey conducted by the VA Office of Analytics and Business Intelligence. Our goals were to: (1) compare rates of negative and positive patient experiences by sex and racial/ethnic groups; and (2) determine whether sex and racial/ethnic differences occur within and/or between VA inpatient facilities.
METHODS Patient Sample and Recruitment Procedures Patients were randomly sampled monthly from VA Medical Centers (VAMCs) from October 2009 to September 2010. Eligible patients were discharged from an acute care VAMC in the previous month; had a medical, surgical, or psychiatric Medicare Severity Diagnosis Related Group (MSDRG) code at discharge; and had not participated in a SHEP administration in the previous 12 months. Sample sizes were designed to have at least 300 completed surveys from patients with medical or surgical MSDRGs per facility in a 12-month period. Following the HCAHPS Quality Assurance Guidelines,22 a survey and cover letter were mailed to patients between 2 and 42 days after discharge. Nonresponders received a second mailing after 21 days, with the data collection period ending 21 days later. All surveys and letters were in English. For this analysis, we excluded respondents from VAMCs outside the 50 states, with a psychiatric MSDRG, or with unreported race/ethnicity. Respondents with psychiatric MSDRG diagnoses were excluded because they are not included in the HCAHPS sampling protocol or calculation of facility performance rates.22 Overall, 58,051 (43.6%) Veterans from 144 VAMCs responded to 133,148 surveys. Respondents were significantly more likely than nonrespondents to be male (95.7% vs. 94.4%), older than 55 years of age (86.1% vs. 70.9%), and in the lowest (groups 7–8) VA priority groups (12.9% vs. 9.6%). After excluding 5575 (9.6%) respondents with a psychiatric MSDRG, 1632 (2.8%) with unspecified race/ethnicity, and 373 (0.6%) from VAMCs outside the 50 states, 50,471 respondents were included in the analyses.
Patient Experiences in VA Hospitals
items measuring cleanliness of hospital environment, quietness of hospital environment, overall hospital rating, and willingness to recommend hospital. VA-specific domains included a multi-item composite measure of shared decision making and single items measuring privacy and noise level, specifically in patients’ rooms. We categorized responses into negative, moderate, and positive experiences for each domain (Appendix, Supplemental Digital Content 1, http://links.lww.com/MLR/A692).23 Consistent with previous work documenting racial/ethnic differences in extreme response tendency (ERT),24 Hispanics in our sample were more likely than whites to use the most positive and negative response categories for most outcomes. ERT was observed for few outcomes among black respondents and was not present among other racial/ethnic minority respondents or women. We selected cut-points for each outcome with the goal of having approximately 10%–15% of responses classified as negative experiences23 and to alleviate issues with ERT by including more moderately negative or positive responses in the negative and positive response categories, respectively. This resulted in the top 2 response categories being categorized as positive for all outcomes with Z5 possible response categories. For outcomes with 3 or 4 response categories, only the top category was categorized as positive.
Independent Variables Our independent variables were respondent sex and race/ ethnicity and the sex and racial/ethnic composition of patients at respondents’ VAMCs. We obtained respondent sex (male or female) from VA administrative data. We obtained respondent race/ethnicity from 2 self-reported items assessing ethnicity and race, which we used to categorize respondents into 4 racial/ ethnic groups: non-Hispanic white (ie, white), non-Hispanic black (ie, black), Hispanic, and non-Hispanic other (ie, other). The other category included groups that were too small to be analyzed separately (ie, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, and multi-racial respondents). To estimate between-facility differences, we used sex and race/ ethnicity data from VA Medical SAS inpatient and outpatient files to calculate the proportions of female patients and patients in each racial/ethnic group who had an inpatient stay at each facility during fiscal year 2010. There was no missing sex data in the administrative sample. Although data on race/ethnicity were missing for 9.8% of this administrative sample, computing the proportion in each racial/ethnic group based on the known data provided estimates very similar to those obtained using more complex missing data methods and utilizing supplemental data sources for race/ethnicity.
Measures Study Outcomes
Control Variables
Outcomes included patient-reported VA health care experiences measured in the 2010 VA SHEP. The SHEP consisted of the HCAHPS instrument6 and items assessing 3 domains of interest to VA (Appendix, Supplemental Digital Content 1, http://links.lww.com/MLR/A692). HCAHPS domains included multi-item composites measuring communication with nurses, with doctors, and about medication; responsiveness of hospital staff; discharge information; and pain management. HCAHPS domains also included single
We controlled for patient characteristics that are typically associated with patient satisfaction and are used to generate case-mix adjusted HCAPHS scores, including age, education, health status, and MSDRG.25 We also controlled for variables that predict patient experiences within the VA health care system and vary by race/ethnicity and sex, including rural versus urban residence and VA priority group. The latter conveys Veterans’ level of eligibility for VA health services, given their financial means
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and service-connected health conditions, with higher priority groups having increased eligibility. We obtained age, residence, and priority group from VA administrative data. We obtained self-reported health status and educational level from the SHEP. Although SHEP assessed primary language spoken at home (English, Spanish, or another), too few respondents spoke a language other than English (n = 820, 1.41%) to adjust for language in the analysis.
Analytic Methods We applied sampling weights to account for the sampling frame and variation in response rate by patient age and sex. All results are based on weighted data. We examined unadjusted rates of negative, moderate, and positive experiences for each domain overall and separately for sex and racial/ethnic groups. We used mixed-effects multinomial regression to examine within-facility and between-facility sex and racial/ethnic differences in negative and positive (vs. moderate) experiences for each domain, adjusting for control variables as fixed effects and facility as a random effect. Models were adjusted for patient age, health status, education, residence, priority group, and MSDRG. Estimating interactions between sex, race/ethnicity, and other demographic variables was not feasible because of relatively small numbers of women and minority respondents. We calculated within-facility and between-facility risk differences representing an adjusted absolute difference in the estimated proportion of patients reporting positive and negative health experiences for each domain. Within-facility risk differences for females were based on patient-level sex and represent the adjusted absolute difference for female patients compared with male patients at the same facility. Within-facility risk differences for each racial/ethnic group were computed in a similar manner and represent the adjusted absolute difference for patients from the specified minority group compared with white patients at the same facility. Between-facility risk differences were computed based on facility-level terms for the proportion of patients belonging to each sex and racial/ethnic group. Betweenfacility risk differences for female patients represent the adjusted absolute difference in the estimated proportion of patients reporting positive or negative health experiences, comparing facilities with a female composition typical of those visited by female patients (5.4%) and facilities with a female composition typical of those visited by male patients (5.2%). Between-facility risk differences for each racial/ ethnic group were computed in a similar manner with a similar interpretation. For example, given that the median proportions of black patients are 33.5% and 14.1% for facilities attended by black respondents and white respondents, respectively, the black between-facility risk difference for positive experiences represents the difference in proportion of patients reporting positive experiences at facilities with 33.5% versus 14.1% black patients. We estimated 95% confidence intervals (CIs) for all risk differences (RDs) using bootstrap methods.26,27 We defined statistical significance using 2-sided tests at the 0.05 level. We used SAS 9.3 (SAS Institute Inc., Cary, NC) software for all analyses.
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RESULTS Respondent Characteristics Of the 50,471 respondents included in the analysis, 1967 (4.5%) were female; 39,725 (75.4%) were white; 6319 (14.7%) were black; 2326 (5.4%) were Hispanic; and 2101 (4.4%) were other race/ethnicity (Table 1). Most respondents were in the older age groups (55–64 y: 37.2%; 65–74 y: 21.9%; 75 y or older: 25.9%), were urban residents (57.5%), and had either a high school diploma (36.0%) or completed some college (34.2%). Significant sex and racial/ethnic differences existed for all patient characteristics (Table 1). Compared with men, women were more frequently racial/ethnic minorities, younger, in better health, more educated, urban residents, and in higher priority groups. Compared with whites, racial/ethnic minorities were more frequently female, younger, urban residents, and in higher priority groups.
Sex Differences in Inpatient Health Care Experiences In unadjusted analyses, women reported significantly more negative and less positive experiences than men in 10 domains (Table 2). For 3 domains (quietness of hospital, noise level in room, and privacy in room), women reported more positive health care experiences (Table 2). Adjusted analyses identified significant within-facility sex differences in negative experiences, with women reporting more negative experiences than men on 4 domains (RD range: 1.83% for discharge information to 5.83% for shared decision making) and less negative experiences on 1 domain (privacy in room; RD = 7.10%; 95% CI: 8.88%, 5.24%) (Table 3). Significant between-facility sex differences indicated more negative experiences at facilities with more female patients for 4 domains (RD range: 0.07% for overall hospital rating to 0.20% for privacy in room). Significant within-facility sex differences in positive experiences indicated that women reported less positive experiences than men for 4 domains (RD range: 4.26% for cleanliness of hospital environment to 8.46% for communication about medication) and more positive experiences for 3 domains (RD range: 4.07% for quietness of hospital environment to 13.21% for privacy in room). Between-facility sex differences indicated significantly less positive experiences at facilities with more female patients for 4 domains (RD range: 0.07% for overall rating of hospital to 0.19% for privacy in room).
Racial/Ethnic Differences in Patient Health Care Experiences In unadjusted analyses (Table 2), blacks reported more negative and less positive experiences than whites for 7 and 6 domains, respectively. However, for 5 domains, blacks reported more positive and less negative experiences. Hispanics reported significantly more negative experiences than whites for 9 domains (ranging from 0.40% to 2.20%). In contrast, Hispanics reported significantly more positive experiences for 10 domains, with differences ranging from 0.10% to 5.70%. Other racial/ethnic respondents reported significantly more negative experiences than whites for all domains and less r
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r
Total Sample (n = 50,471)
2014 Lippincott Williams & Wilkins 8.7 25.6 36.9 21.9 7.0 66.1 33.9 64.6 35.4 49.4 4.9 32.6 0.7 12.4
13.5 34.5 33.8 16.7 4.6 72.1 27.9 57.2 42.8 39.7 6.2 38.8 2.2 13.1
5.4 (4.8, 6.3)
(60.7, 83.2) (9.0, 32.1) (0.8, 6.3) (1.3, 2.5)
0.2 1.3 18.6 53.3 13.7 12.9
6.2 10.9 36.8 33.3 6.8 6.0
76.5 16.6 2.1 1.9
10.0 12.8 26.6 29.7 9.8 11.1
1.2 2.2 10.1 37.5 22.4 26.6
(62.2, 86.2) (8.6, 29.7) (0.8, 5.1) (1.3, 2.4)
66.3 20.3 5.0 8.4
(67.6, 89.0) (7.9, 22.8) (0.8, 4.4) (1.3, 2.4) 5.2 (4.4, 6.0)
80.0 14.1 1.5 1.8
39.5 5.7 38.2 2.3 14.3
51.6 48.4
71.4 28.6
14.1 31.2 33.7 16.6 4.4
6.1 10.3 36.9 32.9 7.2 6.6
1.4 2.1 8.8 36.3 23.4 28.1
3.9
White (n = 39,725)
5.3 (4.6, 6.3)
61.0 (46.7, 75.6) 33.5 (17.8, 42.9) 1.4 (0.8, 4.7) 1.5 (1.1, 1.9)
40.0 7.8 41.5 1.3 9.4
81.0 19.0
74.9 25.1
9.7 32.2 34.3 17.8 5.5
5.2 11.3 34.7 38.1 5.8 4.9
1.5 4.2 19.2 39.7 16.3 19.2
6.2
Black (n = 6319)
(56.2, 78.6) (9.3, 29.7) (3.5, 14.6) (1.7, 3.7) 5.5 (4.9. 6.3)
67.6 13.9 10.2 2.2
42.1 7.4 38.0 2.6 9.9
74.8 25.2
71.0 29.1
11.4 28.9 33.5 19.1 7.1
6.8 11.3 33.4 36.9 7.3 4.4
3.8 4.9 13.3 38.6 18.1 21.3
4.2
Hispanic (n = 2326)
(62.6, 84.9) (9.0, 29.7) (0.8, 6.3) (1.4, 3.4) 5.3 (4.7, 6.0)
77.0 15.0 2.0 2.0
49.8 6.5 34.7 1.0 8.0
57.8 42.2
13.2 31.1 33.7 17.3 4.7
3.8 8.6 28.1 41.4 9.0 9.2
3.4 3.6 13.7 42.7 19.7 17.0
8.6
Otherw (n = 2101)
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5.2 (4.4, 6.0)
78.6 15.1 1.6 1.8
Female (n = 1967)
75.9 14.5 5.5 4.2
Male (n = 48,504)
*All statistics were calculated using weighted data. Differences between males and females and between racial/ethnic groups were tested using w2 tests for categorical variables and t tests or analysis of variance for continuous variables. All differences were statistically significant (P < 0.0001). w Other category included respondents from the following racial/ethnic groups: Native Hawaiian/Pacific Islander (n = 85), Asian (n = 146), American Indian/Alaska Native (n = 562), and multi-racial (n = 1308). HS indicates high school; IQR, interquartile range; MSDRG, Medicare Severity Diagnosis Related Group code at discharge; y, year.
Race/ethnicity (%) White 75.4 Black 14.7 Hispanic 5.4 Other 4.4 Female sex (%) 4.5 Age (%) (y) 18–34 1.6 35–44 2.7 45–54 10.8 55–64 37.2 65–74 21.9 75 or older 25.9 Educational level (%) r8th grade 5.9 Some HS 10.5 HS diploma 36.0 Some college 34.2 4 y degree 7.1 Z4 y degree 6.4 Health status (%) Poor 13.2 Fair 31.2 Good 33.9 Very good 17.0 Excellent 4.7 Discharge MSDRG Medical 71.8 Surgical 28.2 Residential status (%) Urban 57.5 Rural 42.5 VA priority group (%) 1–3 (highest priority) 40.1 4 6.2 5 38.5 6 2.1 7–8 (lowest priority) 13.1 Patient racial/ethnic composition of facility [median (IQR)] % White 78.6 (62.2, 86.2) % Black 15.1 (8.6, 29.7) % Hispanic 1.7 (0.8, 5.1) % Other 1.8 (1.3, 2.4) Patient sex composition of facility [median (IQR)] % Female 5.2 (4.5, 6.0)
Characteristics
TABLE 1. Baseline Characteristics of Respondents by Sex and Race/Ethnicity*
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TABLE 2. Unadjusted Rates of Negative () and Positive (+) Inpatient Health Care Experiences Stratified by Sex and Race/Ethnicity* % Total Dimension of Care (No. Respondents) Communication with nurses (n = 50,430) Communication with doctors (n = 50,429) Communication about medication (n = 28,062) Responsiveness of hospital staff (n = 39,692) Discharge information (n = 43,845) Pain management (n = 32,370) Cleanliness of hospital environment (n = 50,031) Quietness of hospital environment (n = 49,417) Overall rating of hospital (n = 49,459) Willingness to recommend hospital (n = 49,806) Shared decision making (n = 48,275) Privacy in room (n = 48,442) Noise level in room (n = 48,656)
Male
Female
White
Black
Hispanic
Other
+
+
+
+
+
+
+
10.2 9.7 16.3 11.5 7.9 12.7 9.2 16.1 10.9 6.4 23.3 16.1 20.3
70.2 73.3 61.2 59.6 73.2 68.5 70.2 48.1 63.9 68.2 62.4 62.4 56.3
10.1 9.6 16.1 11.4 7.8 12.5 8.8 16.1 10.7 6.3 23.0 16.2 20.3
70.2 73.4 61.7 59.7 73.5 68.6 70.6 47.9 64.4 68.6 62.7 61.9 56.1
12.6 13.3 22.1 14.5 10.5 16.1 16.4 17.1 15.7 9.5 29.4 12.3 20.6
68.7 70.0 52.4 56.8 66.8 67.7 63.1 52.9 53.9 60.5 57.7 72.2 60.8
9.9 9.9 16.6 10.7 7.7 12.3 8.7 16.8 10.4 6.1 23.2 16.3 21.0
69.4 72.6 60.7 59.8 73.6 68.5 70.5 45.2 64.3 69.4 63.0 62.0 55.2
10.8 8.7 15.0 15.0 8.6 13.4 10.6 10.8 11.9 7.2 22.9 14.5 15.2
73.4 75.9 62.7 57.2 71.6 68.6 69.7 62.3 61.4 62.7 59.7 64.2 62.9
10.7 8.6 14.4 12.5 8.1 12.9 11.1 18.5 11.3 6.5 21.9 16.0 23.2
73.7 78.3 66.4 63.6 73.5 71.1 69.3 50.7 69.1 69.3 65.2 63.7 55.3
12.3 11.6 18.2 12.9 9.0 15.8 9.9 18.4 15.5 9.0 27.7 17.7 21.8
68.2 70.1 58.9 59.5 71.4 64.8 68.1 49.0 60.4 65.0 58.3 60.9 56.1
*All rates were calculated using weighted data. All pairwise comparisons between non-Hispanic white and each racial/ethnic minority group were statistically significant at Pr0.001. All pairwise comparisons between males and females were statistically significant at Pr0.001.
positive experiences than whites for 11 domains, with differences ranging from 0.30% to 5.10%. Adjusted analyses identified significant within-facility differences in negative experiences between blacks and whites for 7 domains, with blacks reporting less negative experiences (RD range: 1.49% for communication with doctors to 7.22% for quietness of hospital environment) (Table 3). However, between-facility differences indicated significantly more negative experiences reported by respondents at facilities with more black patients for 9 domains (RD range: 1.12% for discharge information to 4.46% for responsiveness of hospital staff). Within-facility analyses also revealed that blacks reported significantly more positive experiences for 7 domains (RD range: 1.90% for responsiveness of hospital staff to 16.26% for quietness of hospital environment) and less positive experiences for willingness to recommend the hospital (RD = 1.92%; 95% CI: 3.73%, 0.01%). Betweenfacility differences indicated significantly less positive experiences reported by respondents at facilities with more black patients for 10 domains (RD range: 1.71% for privacy in room to 5.25% for responsiveness of hospital staff) but significantly more positive experiences with quietness of hospital environment reported at facilities with more black patients (RD = 2.76%; 95% CI: 1.81%, 3.59%). Adjusted analyses identified 2 significant withinfacility differences in negative experiences for Hispanics, who reported less negative experiences than whites with communication about medication (RD = 3.85%; 95% CI: 5.97%, 1.49%) and privacy in room (RD = 1.83%; 95% CI: 3.80%, 0.10%). In contrast, between-facility analyses indicated significantly more negative experiences reported at facilities with more Hispanic patients for 9 domains (RD range: 0.57% for overall rating of hospital to 2.34% for responsiveness of hospital staff). Within-facility analyses indicated that Hispanics reported more positive experiences than whites for 9 domains (RD range: 2.73% for privacy in room to 7.57% for responsiveness of hospital staff). Between-facility analyses indicated significantly less
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positive experiences reported at facilities with more Hispanic patients for 7 domains (RD range: 1.11% for discharge information to 2.14% for responsiveness of hospital staff). Adjusted analyses identified 3 significant within-facility differences in negative experiences for other race/ethnicity respondents, who reported more negative experiences than whites (RD range: 1.97% for willingness to recommend hospital to 3.64% for shared decision making). There were also small, statistically significant between-facility differences indicating less negative experiences reported at facilities with more other racial/ethnic patients in 5 domains (RD range: 0.09% for overall rating of hospital to 0.25% for privacy in room). Within-facility analyses also indicated that other race/ethnicity respondents reported more positive experiences than whites for quietness of hospital (RD = 4.66%; 95% CI: 1.78%, 7.42%) and less positive experiences for shared decision making (RD = 4.10%; 95% CI: 7.06%, 1.41%). Between-facility analyses indicated significantly more positive experiences reported at facilities with more other race/ethnicity patients for 6 domains (RD range: 0.14% for willingness to recommend hospital to 0.27% for privacy in room).
DISCUSSION We found significant within-facility and betweenfacility sex and racial/ethnic differences in patient-reported experiences in multiple domains in a nationally representative sample of VA inpatients. In adjusted, within-facility analyses, women tended to report more negative and/or less positive experiences than men, although women did report more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics tended to report less negative and/or more positive experiences than whites within the same facility, although patients at facilities with higher proportions of black and Hispanic patients reported more negative and less positive experiences overall. There were r
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Patient Experiences in VA Hospitals
TABLE 3. Adjusted Within-Facility and Between-Facility Risk Differences in Negative and Positive Inpatient Health Care Experiences for Sex and Racial/Ethnic Groups Negative Patient Experiences Dimension of Care For Sex and Racial/Ethnic Groups Communication with nurses Black Hispanic Other Female Communication with doctors Black Hispanic Other Female Communication about medication Black Hispanic Other Female Responsiveness of hospital staff Black Hispanic Other Female Discharge information Black Hispanic Other Female Pain management Black Hispanic Other Female Cleanliness of hospital environment Black Hispanic Other Female Quietness of hospital environment Black Hispanic Other Female Overall rating of hospital Black Hispanic Other Female Willingness to recommend hospital Black Hispanic Other Female Shared decision making Black Hispanic Other Female Privacy in room Black Hispanic Other Female
Within-facility
w
Positive Patient Experiences
Between-facility
z
RD
95% CI
RD
95% CI
1.49* 0.65 1.06 0.70
2.61, 0.42 2.33, 1.26 0.86, 3.01 1.06, 2.38
2.84* 1.13* 0.02 0.03
2.37, 3.60 0.63, 1.65 0.10, 0.05 0.02, 0.09
1.53* 1.63 1.03 1.53
2.60, 0.41 3.19, 0.15 0.68, 3.03 0.03, 3.58
0.13 0.09 0.03 0.00
0.54, 0.34, 0.11, 0.04,
3.58* 3.85* 0.36 4.70*
5.28, 2.00 5.97, 1.49 2.74, 4.00 2.03, 7.94
2.48* 0.66 0.14* 0.01
1.92 1.28 3.02 2.17
Within-facilityw 95% CI
RD
95% CI
7.09* 6.30* 0.66 0.76
5.50, 8.66 3.82, 8.85 2.40, 3.60 2.14, 3.51
2.95* 1.52* 0.05 0.03
3.89, 2.29 2.24, 0.89 0.18, 0.06 0.11, 0.03
3.88* 6.16* 1.60 2.11
2.48, 5.68 3.75, 8.37 4.24, 1.04 5.28, 0.72
0.82 0.00 0.05 0.02
1.66, 3.36 0.23, 1.31 0.29, 0.01 0.07, 0.07
4.67* 6.90* 0.56 8.46*
2.30, 6.92 2.97, 11.05 4.09, 3.35 12.96, 4.70
3.36* 0.51 0.17* 0.03
4.38, 2.26 1.48, 0.48 0.00, 0.35 0.06, 0.14
4.46* 2.34* 0.12* 0.03
3.87, 5.50 1.78, 2.97 0.24, 0.03 0.03, 0.09
1.90* 7.57* 1.94 0.96
0.18, 3.95 4.97, 10.60 1.42, 5.14 2.94, 3.99
5.25* 2.14* 0.00 0.02
6.36, 4.50 3.02, 1.28 0.16, 0.13 0.07, 0.11
1.00, 1.10 1.04, 2.37 0.90, 2.80 0.05, 3.76
1.12* 0.48 0.04 0.02
0.65, 1.59 0.04, 1.00 0.12, 0.02 0.02, 0.07
0.24 0.16 1.38 6.43*
1.83, 1.68 2.37, 2.85 3.87, 1.34 9.49, 3.39
2.49* 1.11* 0.05 0.01
3.47, 1.76 1.92, 0.47 0.16, 0.07 0.09, 0.07
1.06 0.86 1.84 0.30
2.43, 3.07, 0.71, 2.53,
0.60 1.38 4.26 2.03
1.88* 0.95* 0.12 0.02
1.32, 2.78 0.27, 1.71 0.24, 0.01 0.04, 0.09
3.24* 4.72* 1.93 2.86
1.29, 5.32 1.78, 7.87 5.34, 1.37 0.41, 5.81
2.73* 1.34* 0.13 0.00
3.90, 1.93 2.24, 0.29 0.03, 0.26 0.09, 0.08
0.70 1.18 0.19 5.31*
1.78, 0.33 0.46, 2.90 1.60, 2.23 3.25, 7.47
2.92* 1.02* 0.06 0.03
2.43, 3.69 0.56, 1.59 0.18, 0.01 0.03, 0.09
2.07* 0.28 1.13 4.26*
0.22, 3.83 2.16, 2.73 3.84, 1.69 7.18, 1.29
3.84* 1.56* 0.19* 0.02
4.71, 3.03 2.35, 0.89 0.08, 0.34 0.10, 0.07
7.22* 0.20 1.23 0.37
8.41, 5.91 1.82, 2.18 1.26, 3.52 2.51, 2.11
0.28 1.46* 0.05 0.12*
0.41, 0.95 0.90, 2.01 0.15, 0.04 0.06, 0.20
16.26* 5.89* 4.66* 4.07*
18.14 8.81 7.42 7.03
2.76* 0.82 0.12 0.10*
1.81, 3.59 1.64, 0.01 0.00, 0.27 0.20, 0.02
0.57 0.30 3.36* 1.42
1.83, 0.45 2.19, 1.66 1.39, 5.66 0.59, 3.34
2.27* 0.57* 0.09* 0.07*
1.53 7.19* 1.45 2.94
0.30, 3.28 4.88, 9.72 4.48, 1.21 6.61, 0.38
3.71* 0.03 0.16* 0.07*
4.69, 2.98 0.90, 0.68 0.04, 0.27 0.16, 0.00
0.14 0.45 1.97* 0.07
1.10, 0.91 1.79, 1.02 0.13, 3.64 1.34, 1.54
1.16* 0.29 0.06 0.03
0.67, 1.70 0.09, 0.72 0.13, 0.01 0.00, 0.08
1.92* 1.55 2.24 2.74
3.73, 0.01 0.93, 4.38 4.85, 0.87 6.15, 0.27
4.85* 0.04 0.14* 0.03
5.72, 3.95 0.77, 0.68 0.01, 0.25 0.11, 0.04
2.01* 1.69 3.64* 5.83*
3.55, 0.59 4.05, 0.91 1.14, 6.07 2.75, 8.71
1.69* 0.66* 0.09 0.02
1.09, 2.65 0.01, 1.34 0.19, 0.03 0.05, 0.09
1.57 2.82* 4.10* 4.87*
3.33, 0.49 0.19, 5.57 7.06, 1.41 8.17, 1.95
2.68* 0.61 0.08 0.04
3.66, 1.99 1.41, 0.11 0.05, 0.20 0.12, 0.05
1.98* 1.83* 0.52 7.10*
3.42, 0.72 3.80, 0.10 1.88, 3.06 8.88, 5.24
0.68 1.11* 0.25* 0.20*
0.17, 1.43 0.39, 1.78 0.38, 0.15 0.12, 0.30
1.61 2.73* 0.31 13.21*
0.07, 3.42 0.18, 5.53 3.11, 2.67 10.38, 15.79
1.71* 1.65* 0.27* 0.19*
2.58, 2.50, 0.13, 0.29,
0.61 0.61 0.73 0.09 0.11 0.55 0.86 1.83*
0.68, 2.29, 1.34, 2.26,
1.74, 0.13, 0.18, 0.02,
0.50 0.55 0.05 0.06
3.05 1.10 0.01 0.13
RD
Between-facilityz
14.58, 3.28, 1.78, 0.87,
0.05, 0.64, 0.07, 0.10,
1.50 0.69 0.17 0.05
0.76 0.85 0.42 0.08
(Continued )
r
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TABLE 3. Adjusted Within-Facility and Between-Facility Risk Differences in Negative and Positive Inpatient Health Care Experiences for Sex and Racial/Ethnic Groups (continued) Negative Patient Experiences Dimension of Care For Sex and Racial/Ethnic Groups Noise level in room Black Hispanic Other Female
Within-facility
w
Positive Patient Experiences
Between-facility
z
RD
95% CI
RD
95% CI
6.37* 0.84 0.08 2.25
8.06, 5.01 1.57, 3.09 2.13, 2.79 4.80, 0.41
0.16 1.49* 0.12* 0.13*
0.58, 0.93 0.83, 2.19 0.27, 0.03 0.06, 0.20
Within-facilityw RD 7.99* 1.54 2.14 6.62*
Between-facilityz
95% CI
RD
95% CI
6.28, 9.75 1.12, 4.56 1.21, 5.31 3.47, 9.28
0.05 1.60* 0.23* 0.18*
0.98, 0.94 2.39, 0.83 0.13, 0.39 0.28, 0.10
Models adjusted for patient age, education, health status, medical or surgical Medicare Severity Diagnosis Related Group code at discharge, rural versus urban residence, and VA priority group. *P < 0.05. RD > 0 for negative experiences and RD < 0 for positive experiences indicate less positive experiences for female (vs. male) and racial/ethnic minority (vs. white) patients. Significant differences reflecting less positive experiences for female or racial/ethnic minority patients are in bold. w Within-facility risk differences for females represent the adjusted absolute difference for female patients compared with male patients. Within-facility risk differences for each racial/ethnic group represent the adjusted absolute difference for patients from the specified minority group compared with non-Hispanic white patients. z Between-facility risk differences for females represent the adjusted absolute difference in the estimated proportion of patients reporting negative or positive health experiences comparing facilities with a female composition typical of those visited by female patients (proportion of female patients at the facility set to the median value for female respondents) to facilities with a female composition typical of those visited by male patients. Between-facility risk differences for each racial/ethnic group represent the adjusted absolute difference in the estimated proportion of patients reporting negative or positive health experiences comparing facilities with a minority composition typical of those visited by the specified minority group (proportion of patients from that minority group at the facility set to the median for respondents of that racial/ethnic minority group) to facilities with a minority composition typical of those visited by non-Hispanic white patients. CI indicates confidence interval; RD, risk difference.
few and inconsistent within-facility differences between other racial/ethnic patients and whites, and slightly less negative and more positive experiences at facilities with more other racial/ethnic patients. Some of the observed sex differences are similar to those found among inpatients from non-VA hospitals, where men have reported more positive experiences for communication about medications, discharge information, and hospital cleanliness.7 However, women in our sample also reported more positive experiences on quietness of the hospital, privacy of room, and noise level of room. This may be due to efforts in VA facilities to protect the privacy of women inpatients that might result in women having a private room more often than men. Some racial/ethnic differences observed in this study are similar to those reported in previous studies. The more positive experiences reported by black and Hispanic patients compared with white patients within the same facilities are consistent with work outside VA in which blacks and Hispanics report similar, and in some cases more positive, health care experiences than whites.8–10,14,16,17,19 Less positive experiences at inpatient institutions serving more black and Hispanic patients have also been observed in VA outpatients, non-VA inpatients, and Medicaid managed-care populations.10,18,21 However, the within-facility differences we observed showing more positive experiences for black and Hispanic inpatients were of greater magnitude and for more health care domains than in a similar study of VA outpatients.21 These differences could be because of differences in the patient mix in VA outpatient and inpatient settings, as inpatients tend to be older, have poorer health status, and are being treated for more serious conditions. The inpatient survey is also tied to a specific hospitalization, whereas the outpatient survey assesses all experiences with VA care received over the last 12 months. Further, among VA outpatients and in most non-VA samples, patients from racial/ethnic minority
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groups other than black and Hispanic generally report worse health care experiences than whites.9–14,18,19,21 In our sample, however, there were few and inconsistent within-facility differences between other racial/ethnic patients and whites, and there were very small between-facility differences. The unexpected pattern for this group could be because of its relatively small sample size (n = 2101) or its heterogenous composition. It included Asians (7%), Native Hawaiian/Pacific Islanders (4%), American Indian/Alaska Natives (27%), and multi-racial patients (73% of whom were American Indian/Alaska Native and at least one other race), whereas other studies examined Asians and American Indian/Alaska Natives separately.9–13,18 Our findings have implications for future initiatives to ensure equitable health care experiences across sex and racial/ethnic groups in VA inpatient facilities. Efforts to address sex differences should target specific domains in which women report less positive experiences than men, including communication about medications, cleanliness of hospital, and use of shared decision making. Given that men reported significantly less positive experiences with privacy and noise, VA may also need to take steps to improve noise levels and provide privacy equitably for both men and women receiving inpatient care. Our findings suggest that efforts to ensure equitable experiences across racial/ethnic groups should focus on VA inpatient facilities serving higher proportions of black and Hispanic patients. Our study also has implications for assessing and reporting sex and racial/ethnic differences in VA inpatient experiences. First, women and minority patients, especially those in the other racial/ethnic group, need to be over-sampled in VA surveys to estimate differences for these groups and to examine interactions between patient sex, race/ethnicity, and other characteristics. Our findings also underscore the importance of distinguishing within-facility from between-facility effects when assessing and reporting sex r
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Medical Care
Volume 52, Number 4, April 2014
and racial/ethnic differences in VA inpatient experiences. Given that within-facility and between-facility differences often are in opposite directions within a given health care domain, assessing overall patient health care experiences may obscure the true magnitude of sex and racial/ethnic differences. We acknowledge that this study has limitations. First, the study sampling frame for administering HCAHPS surveys22 did not account for respondent race or ethnicity, so we could not assess racial/ethnic differences in response rates. Second, the racial/ethnic and sex composition of our sample did not allow us to examine experiences separately for Asian American/Pacific Islanders, Native Americans/Alaska Natives, and multi-racial patients, or to test interactions between race/ethnicity, sex, and other patient characteristics. The heterogeneity of the other racial/ethnic group makes it difficult to make generalizations about the health care experiences of this group. The restricted range in proportions of women and other racial/ ethnic minority patients across facilities also limits our ability to detect between-facility effects of sex and for the other racial/ ethnic group. Third, our 44% response rate may have led to biases in our study sample. Fourth, the within-facility differences showing more positive experiences for black and Hispanic respondents could be partly due to ERT among these groups,17,24 although we attempted to reduce the impact of ERT in our construction of negative, moderate, and positive response categories. Finally, it is unclear whether the observed self-reported differences were because of patient preferences, expectations, or actual differences in patient experiences. In summary, our national study of sex and racial/ethnic differences in experiences of VA inpatients demonstrates that male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities, whereas health care experiences are less positive overall in hospitals that serve more female, black, and Hispanic patients. Our findings have important implications for assessing sex and racial/ethnic differences in patient experiences in the VA Healthcare System. It also helps identify targets for interventions to reduce sex and racial/ethnic differences in health care experiences by focusing efforts on specific domains and by targeting efforts at facilities with larger female, black, or Hispanic patient populations. REFERENCES 1. National Center for Veterans Analysis and Statistics. FY 10 Summary of Expenditures by State. Available at: http://www.va.gov/vetdata/docs/ GDX/GDX_FY10_V1_41.xlsx. Accessed February 9, 2012. 2. National Center for Veterans Analysis and Statistics. Table 5L: Veterans 2000-2036 by race/ethnicity, gender, period, age. Available at: http://www1. va.gov/VETDATA/docs/Demographics/5l.xls. Accessed March 15, 2013. 3. National Center for Veterans Analysis and Statistics. Table 3L: VETPOP2011 living veterans by race/ethnicity, gender, 2010-2040. Available at: https://www.va.gov/VETDATA/docs/Demographics/ New_Vetpop_Model/3lVetPop11_Race_National.xlsx. Accessed March 15, 2013. 4. Kressin NR, Skinner K, Sullivan L, et al. Patient satisfaction with Department of Veterans Affairs health care: do women differ from men? Mil Med. 1999;164:283–288.
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Patient Experiences in VA Hospitals
5. Wright SM, Craig T, Campbell S, et al. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med. 2006;21(suppl 3):S26–S32. 6. HCAHPS Survey. Centers for Medicare & Medicaid Services. Available at: http://www.hcahpsonline.org/Files/1HCAHPS%20V7%200%20 Appendix%20 A%20-%20HCAHPS%20STANDARD%20Mail%20 Survey%20Materials%20%28English%29%20March%202012.pdf. Accessed January 23, 2013. 7. Elliott MN, Lehrman WG, Beckett MK, et al. Gender differences in patients’ perceptions of inpatient care. Health Serv Res. 2012;47:1482–1501. 8. Hunt KA, Gaba A, Lavizzo-Mourey R. Racial and ethnic disparities and perceptions of health care: does health plan type matter? Health Serv Res. 2005;40:551–576. 9. Weech-Maldonado R, Morales LS, Elliott M, et al. Race/ethnicity, language, and patients’ assessments of care in Medicaid managed care. Health Serv Res. 2003;38:789–808. 10. Weech-Maldonado R, Elliott MN, Morales LS, et al. Health plan effects on patient assessments of Medicaid managed care among racial/ethnic minorities. J Gen Intern Med. 2004;19:136–145. 11. Haviland MG, Morales LS, Dial TH, et al. Race/ethnicity, socioeconomic status, and satisfaction with health care. Am J Med Qual. 2005;20:195–203. 12. Morales LS, Elliott MN, Weech-Maldonado R, et al. Differences in CAHPS adult survey reports and ratings by race and ethnicity: an analysis of the National CAHPS benchmarking data 1.0. Health Serv Res. 2001;36:595–617. 13. Haviland MG, Morales LS, Reise SP, et al. Do health care ratings differ by race or ethnicity? Jt Comm J Qual Saf. 2003;29:134–145. 14. Lurie N, Zhan C, Sangl J, et al. Variation in racial and ethnic differences in consumer assessments of health care. Am J Manag Care. 2003;9: 502–509. 15. Merrill RM, Allen EW. Racial and ethnic disparities in satisfaction with doctors and health providers in the United States. Ethn Dis. 2003; 13:492–498. 16. Bagchi AD, Schone E, Higgins P, et al. Racial and ethnic health disparities in TRICARE. J Natl Med Assoc. 2009;101:663–670. 17. Dayton E, Zhan C, Sangl J, et al. Racial and ethnic differences in patient assessments of interactions with providers: disparities or measurement biases? Am J Med Qual. 2006;21:109–114. 18. Goldstein E, Elliott MN, Lehrman WG, et al. Racial/ethnic differences in patients’ perceptions of inpatient care using the HCAHPS survey. Med Care Res Rev. 2010;67:74–92. 19. Shi L, Macinko J. Changes in medical care experiences of racial and ethnic groups in the United States, 1996-2002. Int J Health Serv. 2008;38:653–670. 20. Rodriguez HP, von Glahn T, Grembowski DE, et al. Physician effects on racial and ethnic disparities in patients’ experiences of primary care. J Gen Intern Med. 2008;23:1666–1672. 21. Hausmann LRM, Gao S, Mor MK, et al. Understanding racial and ethnic differences in patient experiences with outpatient care in U.S. Veterans Affairs Medical Centers. Med Care. 2013;51:532–539. 22. CAHPSs Hospital Survey (HCAHPS) Quality Assurance Guidelines Version 7.0. Centers for Medicare & Medicaid Services. Available at: http://www.hcahpsonline.org/files/HCAHPS%20Quality%20Assurance %20Guidelines%20V7.0%20March%202012.pdf. Accessed January 23, 2013. 23. Elliott MN, Beckett MK, Kanouse DE, et al. Problem-oriented reporting of CAHPS consumer evaluations of health care. Med Care Res Rev. 2007;64:600–614. 24. Weech-Maldonado R, Elliott MN, Oluwole A, et al. Survey response style and differential use of CAHPS rating scales by Hispanics. Med Care. 2008;46:963–968. 25. O’Malley AJ, Zaslavsky AM, Elliott MN, et al. Case-mix adjustment of the CAHPS Hospital Survey. Health Serv Res. 2005;40:2162–2181. 26. Austin PC. Absolute risk reductions, relative risks, relative risk reductions, and numbers needed to treat can be obtained from a logistic regression model. J Clin Epidemiol. 2009;63:2–6. 27. Efron B, Tibshirani RJ. An Introduction to the Bootstrap. Boca Raton, FL: Chapman & Hall/CRC; 1993.
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