Exploring the association of care fragmentation and patient ratings of care quality: A mediation analysis of women Veterans’ experience with VA care

Abstract

Objective To examine the relationship between care fragmentation and patient ratings of care quality and identify potentially actionable mediators. Data Sources/Study Setting 2015 telephone survey of 1395 women Veterans with three or more visits in primary care and/or women's health care in the prior year at 12 Veterans Affairs (VA) medical centers. Study Design Cross‐sectional analysis. Data Collection/Extraction Methods We operationalized lower care fragmentation as receiving VA‐only care versus dual use of VA/non‐VA care. Participants rated VA care quality (overall care, women's health care (WH), and primary care (PC)) and three aspects of their patient experience (ease of access to services, provider communication, and gender sensitivity of VA environments). We examined associations between care fragmentation and care ratings and applied the Karlson‐Holm‐Breen decomposition method to test for mediation by aspects of patients’ experience. Principal Findings Lower care fragmentation was associated with higher ratings of care quality (odds ratios [95% CI] for overall care: 1.57 [1.14;2.17]; WH: 1.65 [1.20;2.27]; PC: 1.41 [1.10;1.82]). Relationships were mediated by patient‐rated provider communication and gender sensitivity (26‐54 percent and 14‐15 percent of total effects, respectively). Ease of access was associated with higher care ratings (odds ratios [95% CI] for overall care: 2.93 [2.25;3.81]; WH: 2.81 [2.15;3.68]; PC: 2.33 [1.63;3.33], in models with the three types of patient care experiences included), but did not mediate the association of care fragmentation and care ratings. Conclusions Potential negative effects of care fragmentation on care quality ratings could be mitigated by attention to quality of patient‐provider communication and gender sensitivity of VA environments.

Changes in Health Care Use and Outcomes After Turnover in Primary Care

“…ontinuity of care, a core principle of high-quality primary care, is associated with improved quality of care [1][2][3][4][5] and patient outcomes, [6][7][8][9][10] including greater delivery of preventive services and lower rates of hospitalization and emergency department visits, as well as lower costs of care for chronic illness. [8][9][10] Based on this evidence, strengthening the relationship between patients and primary care physicians (PCPs) has been a centerpiece of delivery reform efforts targeting highcost and uncoordinated care.…”

Healthcare Access among Older Rural Women Veterans in Utah*

“…Furthermore, it is critical that social scientists examine veterans' experiences with, for example: (1) coordinating care among different healthcare providers; (2) using different types of insurance (cf. Chanfreau‐Coffinier et al 2019); and (3) the care options available to aging rural veterans as they plan for and enter retirement.…”

“…In a recent case study of urban women veterans (Evans et al 2019:25) which explored why women veterans do not use VA healthcare, reasons identified were related to women's perceptions of the accessibility, appropriateness, and acceptability of the VA environment and services. Research by Chanfreau‐Coffinier et al (2019), which also examined perceptions of healthcare among women veterans, found that women's views of the quality of care was affected by their use of different healthcare sources—VA and non‐VA. Specifically, higher quality ratings were associated with less fragmented healthcare use.…”

Optimal staffing in community health centers to improve quality of care

“…For Equations () and (), the volume of services serves as a dependent variable in Equation () and an independent variable in Equation (). This method is also known as mediation analysis, where the direct effect (ie, the effect of labor and capital inputs on quality in Equation ()) and the indirect effect of independent variables (ie, the effect of labor and capital inputs on quality mediated through Equation () and volume term in Equation ()) can be estimated separately 54‐56 . Appendix Figure presents a conceptual path diagram for this mediation analysis.…”