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Military Sexual Trauma and Patient Perceptions of Veteran Health Administration Health Care Quality

      Abstract

      Background

      Although sexual trauma is associated with poorer patient perceptions of health care quality, few studies have investigated this relationship in settings with comprehensive policies surrounding detection and treatment of sexual trauma, such as the Veterans Health Administration (VHA). We examined the association of military sexual trauma (MST) with patient satisfaction with VHA outpatient care among men and women.

      Methods

      This is a cross-sectional study of a national representative sample of 164,632 VHA outpatients (5,758 women and 158,884 men) from fiscal year 2007. Measures included MST status, patients’ ratings of overall satisfaction with VHA care in the last 2 months, and nine other dimensions of patient satisfaction. We assessed bivariate and multivariate associations between MST and overall satisfaction and each dimension of patient satisfaction. Multivariate models were adjusted for demographic characteristics, health status, and medical utilization. All analyses were stratified by gender.

      Findings

      The proportion of patients reporting very good or excellent overall satisfaction was 78.5% for men and 72.3% for women. Findings showed that, once confounding was controlled, men and women veterans’ MST status was not associated with satisfaction ratings of VHA health care overall. However, women veterans with a history of MST rated the dimensions of overall coordination and education and information less favorably than women veterans without an MST history. Post hoc analysis of individual items in these domains suggested that areas of improvement might include greater attention to provider–patient communication, including communication across multiple providers. There was no association between men’s MST status and subdomains of health care satisfaction.

      Conclusion

      Patient ratings of overall satisfaction of VHA care are high. Opportunities exist, however, to educate providers on the special coordination needs of female veterans with histories of MST. These female veterans might benefit from care coordination. When investigating satisfaction in patients with histories of sexual trauma, our findings suggest the importance of adjusting analyses for important patient characteristics.

      Introduction

      Sexual trauma is common among women seeking medical care, and women who have experienced sexual trauma often rate health care experiences, provider communication, and satisfaction more poorly than women who do not report such experiences (
      • Bassuk E.L.
      • Dawson R.
      • Perloff J.
      • Weinreb L.
      Post-traumatic stress disorder in extremely poor women: Implications for health care clinicians.
      ,
      • McNutt L.A.
      • van Ryn M.
      • Clark C.
      • Fraiser I.
      Partner violence and medical encounters: African-American women’s perspectives.
      ,
      • Plichta S.B.
      • Falik M.
      Prevalence of violence and its implications for women’s health.
      ). A recent study found lower estimates of satisfaction with Veterans Health Administration (VHA) care among women veterans with a history of sexual violence while in the military than those without similar histories (
      • Kelly M.M.
      • Vogt D.S.
      • Scheiderer E.M.
      • Ouimette P.C.
      • Daley J.
      • Wolfe J.
      Effects of military trauma exposure on women veterans’ use and perceptions of Veterans Health Administration care.
      ). In VHA, military sexual trauma (MST), defined as severe sexual harassment or sexual assault during active military duty, is reported by approximately 22% of female veterans and 1% of male veterans who utilize the VHA (
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.E.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      ).
      Although the vast number of veterans who have experienced MST and use VHA services may predict ratings of poor satisfaction, the VHA’s unique, comprehensive, and national approach to MST identification and treatment could contribute to higher ratings of satisfaction. The VHA is a national leader in MST management and abides by numerous public laws and directives aimed at providing expansive services for MST-related care. Policies such as universal screening for MST, system-wide educational initiatives, and MST coordinators at each medical center are integrated into VHA standards for the provision of mental health services (
      Veterans Health Administration (VHA)
      Uniform Mental Health Services in VA Medical Centers and Clinics, VHA Handbook, 1160.01.
      ). VHA monitoring reports consistently indicate that every VHA medical center across the nation provides MST-related mental health care (
      Military Sexual Trauma Support Team
      Summary of military sexual trauma-related outpatient care: Fiscal year 2007.
      ,
      Military Sexual Trauma Support Team
      Summary of military sexual trauma-related outpatient care: Fiscal year 2008.
      ), and although MST is associated with a heterogeneity of mental health conditions (
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.E.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      ,
      • Kimerling R.
      • Street A.E.
      • Pavao J.
      • Smith M.
      • Cronkite R.
      • Holmes T.H.
      • et al.
      Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq.
      ), detection of MST via universal screening has been shown to promote access to VHA mental health services (
      • Kimerling R.
      • Street A.E.
      • Gima K.
      • Smith M.W.
      Evaluation of universal screening for military-related sexual trauma.
      ).
      Using a 1997 survey of a community sample of women veterans,
      • Kelly M.M.
      • Vogt D.S.
      • Scheiderer E.M.
      • Ouimette P.C.
      • Daley J.
      • Wolfe J.
      Effects of military trauma exposure on women veterans’ use and perceptions of Veterans Health Administration care.
      reported that a history of military sexual assault was associated with lower satisfaction with VHA care. These data, however, were collected in the early years of VHA’s authorization to provide MST-related care and counseling, when services were significantly less comprehensive than they are today. Additionally, the models in the study did not adjust for demographic characteristics associated with patient satisfaction, which can influence the observed relationship among military sexual assault and patient satisfaction. Lastly, the study’s focus was women veterans. Few data address patient perceptions of health care among men who report sexual trauma, either within or outside of the VHA. Given that VHA patients are predominantly male, and that there is a roughly commensurate population of male and female MST patients seen in VHA, perceptions of health care quality among male veterans need to be examined as well. The aim of the present study was to investigate the association between a history of MST and patient satisfaction with health care in a nationally representative sample of VHA outpatients. The analyses will build on
      • Kelly M.M.
      • Vogt D.S.
      • Scheiderer E.M.
      • Ouimette P.C.
      • Daley J.
      • Wolfe J.
      Effects of military trauma exposure on women veterans’ use and perceptions of Veterans Health Administration care.
      exploration of patient satisfaction with VHA care among veterans reporting sexual assault, but will account for the potential influence of demographic factors and health status, and include both women and men. This investigation presents an opportunity to better understand patient perceptions of care in VHA and represents one of the first assessments of patient perceptions of the quality of care associated with the comprehensive detection and treatment efforts for MST in this system.

      Methods

      Design and Study Population

      This is a cross-sectional investigation of the association of MST status to patient satisfaction among a representative sample of VHA outpatients in fiscal year 2007. The study sample includes all veterans who completed the Survey of Healthcare Experiences of Patients (SHEP) Ambulatory Care (

      Office of Quality and Performance. (2007). Results of: Survey of Healthcare Experiences of Patients FY 2007 Fourth Quarter Outpatient SHEP Results. Available: http://www.oqp.med.va.gov. Accessed January 12, 2010.

      ) between December 2006 and December 2007 (n = 237,828). Of the 237,828 veterans with SHEP data, 215,307 (90.5%) were screened for MST at the time of the survey and 214,201 (99.5%) had a valid yes or no response to the MST screen. We excluded veterans with missing SHEP data for demographic variables and overall satisfaction yielding a final sample of 164,642 (76.9%) veterans, namely, 5,758 women and 158,884 men. This study was approved by the Stanford University Human Subjects Research Institutional Review Board.

      Data Sources

      The SHEP is administered by the VHA Office of Quality and Performance and is used to support VHA quality improvement. The survey is mailed on a monthly basis to a stratified, random sample based on VHA outpatient utilization data files from the previous month. The SHEP asks patients questions about their most recent VHA clinic visit and their overall care at VHA in the last 2 months. The SHEP questions are modeled off instruments first developed by the Picker Institute, with adaptations based on focus groups with veterans and their families (
      American Hospital Association & The Picker Institute
      Eye on patients: Excerpts from a report on patients’ concerns and experiences about the health care system.
      ,
      • Young G.J.
      • Charns M.P.
      • Barbour G.L.
      Quality improvement in the US Veterans Health Administration.
      ). The Picker Institute method has been used to measure patient satisfaction in a variety of hospitals nationwide. The SHEP utilizes a stratified sample to ensure representation of new primary care patients, established primary care patients, and specialty care patients from each VHA medical facility or clinic. Detailed information regarding the methods used to collect SHEP data are available elsewhere (
      • Wright S.M.
      • Craig T.
      • Campbell S.
      • Schaefer J.
      • Humble C.
      Patient satisfaction of female and male users of Veterans Health Administration services.
      ).
      The MST Support Team Data Archive contains archival MST screening status and dates of screening from the MST clinical reminder for all veterans from fiscal year 2002 through fiscal year 2009. It is maintained by the VHA’s MST Support Team and is updated annually. The MST Support Team Data Archive was matched to the SHEP using encrypted social security numbers to obtain MST screening status at the time of the SHEP survey.

      Measures

      Overall satisfaction

      Overall satisfaction with VHA care is measured in the SHEP survey with the question, “Overall, how would you rate the quality of care you received during the past 2 months?” Satisfaction responses were recoded into a dichotomous variable, highly satisfied versus less satisfied. Ratings of satisfaction of very good or excellent were categorized as high satisfaction, and ratings of satisfaction as good, fair, or poor were categorized as low satisfaction. This categorization was selected to be consistent with previous literature (
      • Wright S.M.
      • Craig T.
      • Campbell S.
      • Schaefer J.
      • Humble C.
      Patient satisfaction of female and male users of Veterans Health Administration services.
      ) and with the high standards of VHA’s Veteran Health Care Service Standards, which state the goal for very good or excellent satisfaction (VHA Directive 2006-041).

      Dimensions of satisfaction

      In addition to overall satisfaction, nine dimensions of satisfaction with outpatient care are included on the SHEP, and these dimensions correspond to VHA’s Veteran Health Care Service Standards (VHA Directive 2006-041). Each dimension of patient satisfaction is a composite of up to seven multiple choice or yes or no questions. The dimensions include: overall coordination (six items), continuity (one item), access (seven items), courtesy (two items), education and information (seven items), emotional support (four items), patient preferences (five items), visit coordination (five items), and specialist care (four items). The final score for each dimension of satisfaction was measured as the percent of questions within that dimension wherein the patient indicated he/she was highly satisfied.

      MST

      Since 2002, the VHA has used a clinical reminder in the electronic medical record to screen for MST. The brief screen prompts clinicians to ask the following questions: “While you were in the military. 1) Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks? 2) Did someone ever use force or threat of force to have sexual contact with you against your will?” The VHA codes patients as positive for a history of MST if they respond affirmatively to either screening item. MST screen status was determined as the most recent screen as of the date of the outpatient visit selected for the SHEP survey.

      Patient Characteristics

      The following patient characteristics were included as predictors of satisfaction: Age, race, ethnicity, marital status, education, annual income, employment status, health insurance, Medicare, service connection, and current health status. Service connection refers to a veteran’s eligibility for VHA services for a disability caused by an injury or illness incurred in or aggravated by military service. All responses were self-reported by the patient during the SHEP survey. Additionally, we included two variables that examined patients’ VHA utilization. VHA utilization in the previous year was calculated based on the number of VHA outpatient visits in the previous year and separated into three groups of low (bottom quartile, <2 visits), medium (middle quartiles, 2–12 visits), or high (upper quartile, >12 visits) utilization. Outpatient visit type was defined as the type of clinic visit that the patient was sampled from for the SHEP survey, either primary care, mental health care, or specialty care.

      Analysis

      All analyses were stratified by gender. We tested bivariate associations between patient characteristics (age, race, ethnicity, marital status, education, annual income, employment status, health insurance, Medicare, service connection, current health status, VHA utilization in the previous year, and type of index visit) and both MST status and overall satisfaction using Chi-square tests. Results that are statistically significant at p < .05 are described. All patient characteristics were included in multivariate models, as previous research found all patient characteristics to be predictors of overall satisfaction among VHA outpatient care users (
      • Wright S.M.
      • Craig T.
      • Campbell S.
      • Schaefer J.
      • Humble C.
      Patient satisfaction of female and male users of Veterans Health Administration services.
      ). Logistic regression equations were constructed to predict separate models for overall satisfaction and continuity as a function of MST status and patient characteristics. Linear regression equations were constructed to predict all other dimensions of satisfaction as a function of MST status and patient characteristics. Adjusted means for each dimension of satisfaction were calculated and compared between patients with a history of MST and patients without a history of MST. Significant differences were tested using a two-sided significance level of p < .05. To account for the complex sample design and to provide population estimates of the total VHA outpatient population, sample weights were used. All analyses were conducted using the SVY command in STATA 10.0 (StataCorp, Inc., College Station, TX).
      We conducted a post hoc analysis among women patients, using a logistic regression to examine each item of two subscales—overall coordination and education and information—for the items’ associations with MST status. Adjusted means for all items included in the subscales were calculated and compared between patients with a history of MST and patients without a history of MST.

      Results

      The overall satisfaction proportions were generally high for the sample, at 72.3% for women and 78.6% for men. Proportions of veterans who reported MST were similar to VHA population estimates; 24.6% of women and 1.1% of men had a history of MST at the time of their survey.

      Patient Characteristics and MST

      The comparison of patient characteristics by MST status for women and men is shown in Table 1. Among women, a history of MST was significantly associated with younger age, Hispanic ethnicity, higher education levels, middle income level, high utilization of VHA in the past year, service connection, fair/poor health status, no Medicare coverage or health insurance, and a mental health clinic visit. Among men, a history of MST was significantly associated with younger age, being never married, higher education levels, high utilization of VHA in the past year, service connection, fair/poor health status, no Medicare coverage or health insurance, and a mental health clinic visit.
      Table 1MST Screen Status by Patient Characteristics and Gender
      Women (n = 5,758)p-ValueMen (n = 158,884)p-Value
      MST+ (n = 1,149), %MST− (n = 4,609), %MST+

      (n = 1,591), %
      MST− (n = 157,293), %
      Age group (yrs)<.0001<.0001
       <4524.721.33.82.7
       45–5442.530.917.98.5
       55–6424.219.642.232.2
       ≥658.528.236.156.6
      Race.115.828
       White66.472.883.984.9
       Black25.321.011.611.1
       Other8.36.24.54.0
      Ethnicity.029.546
       Hispanic6.33.44.64.0
       Not Hispanic93.796.795.496.0
      Marital status.675<.0001
       Married28.630.952.562.4
       Divorced/separated/widowed52.652.131.730.2
       Never married18.817.115.96.4
      Education.003<.0001
       High school13.121.438.149.9
       Some college46.245.040.131.3
       College graduate or beyond40.733.621.818.8
      Income ($).004.543
       ≤30,00059.567.968.868.3
       30,001–60,00033.023.324.923.9
       ≥60,0017.58.76.37.9
      Employment.953.758
       Wages/self-employed34.534.720.820.1
       Unemployed/out of the workforce65.565.379.379.9
      VHA utilization in previous year.002<.0001
       Low6.910.16.512.0
       Medium26.234.131.038.9
       High66.955.862.549.1
      Service connection<.0001<.0001
       Service connected66.746.951.440.7
       Not service connected33.353.248.659.3
      Health status.039.001
       Excellent/very good/good59.365.848.757.4
       Fair/poor40.734.251.342.6
      Medicare.007.003
       Yes29.838.557.965.6
       No70.261.642.134.4
      Health insurance.008<.0001
       Yes29.237.730.541.7
       No70.862.369.558.3
      Type of clinic visit<.0001<.0001
       Mental health clinic27.712.124.29.1
       Specialty clinic50.155.949.258.9
       Primary care clinic21.532.026.632.0
      Abbreviations: MST, military sexual trauma; MST+, patients with a history of MST; MST−, patients without a history of MST.

      Patient Characteristics and Overall Satisfaction

      Comparisons of overall satisfaction proportions by patient characteristics for both women and men are shown in Table 2. Among both women and men, lower overall satisfaction proportions were significantly associated with younger age, race other than White, being divorced or never married, service connection, fair/poor health status, and having no Medicare coverage. In addition, among men lower overall satisfaction proportions were also significantly associated with Hispanic ethnicity, lower levels of education and income, being unemployed, high VHA utilization in the past year, not having health insurance, and having a mental health visit.
      Table 2Overall Satisfaction by Patient Characteristics and Gender
      Overall Satisfaction (%), Women (n = 5,758)p-ValueOverall Satisfaction (%), Men (n = 158,884)p-Value
      Age group (yrs)<.0001<.0001
       <4564.864.8
       45–5469.171.3
       55–6473.176.9
       ≥6583.281.4
      Race.001<.0001
       White75.280.4
       Black63.768.3
       Other68.670.7
      Ethnicity.197<.0001
       Hispanic64.271.8
       Not Hispanic72.678.9
      Marital status.007<.0001
       Married76.479.9
       Divorced/separated/widowed72.576.5
       Never married64.476.4
      Education.354<.0001
       High school74.977.8
       Some college72.977.9
       College graduate or beyond70.082.1
      Income ($).107<.0001
       ≤30,00071.077.2
       30,001–$60,00072.780.9
       ≥60,00180.984.4
      Employment.652.031
       Wages/self-employed73.179.6
       Unemployed/out of the workforce71.878.4
      VHA utilization in previous year.193<.0001
       Low74.282.0
       Medium75.079.9
       High70.576.8
      Service connection<.0001<.0001
       Service connected67.676.0
       Not service connected77.380.5
      Health status<.0001<.0001
       Excellent/very good/good77.762.0
       Fair/poor62.538.0
      Medicare<.0001<.0001
       Yes79.180.1
       No68.375.8
      Health insurance.060<.0001
       Yes75.580.6
       No70.577.3
      Type of clinic visit.165<.0001
       Mental health clinic73.674.9
       Specialty clinic70.378.4
       Primary care clinic75.280.1
      Overall satisfaction is defined as the percent of patients rating their quality of care received in the last 2 months as very good or excellent.

      Satisfaction and MST

      The unadjusted and adjusted mean scores for overall satisfaction and each dimension of satisfaction by MST screen status for men are shown in Table 3. Compared with men without a history of MST, men with a history of MST had lower unadjusted mean scores for the following dimensions of satisfaction: Overall satisfaction, overall coordination, continuity, access, courtesy, education and information, emotional support, patient preferences, and visit coordination (p < .05). After adjusting for patient characteristics, none of the mean satisfaction scores were significantly different by MST screen status.
      Table 3Unadjusted and Adjusted Mean Scores for Overall Satisfaction and Dimensions of Satisfaction Stratified by MST Status, Men (n = 158,884)
      Unadjusted ScoresAdjusted Scores
      Adjusted mean scores derived from regression models using the following patient characteristics: Age, race, ethnicity, marital status, education, income, employment, VHA utilization in previous year, service connection, health status, Medicare, health insurance, and type of clinic visit.
      p-Values for

      Differences by MST
      MST+MST−MST+MST−UnadjustedAdjusted
      Overall satisfaction73.378.778.481.2.018
      p < .05.
      .179
      Overall coordination69.976.076.078.5.001
      p < .05.
      .157
      Continuity73.778.375.678.7.047
      p < .05.
      .174
      Access78.481.883.684.6.014
      p < .05.
      .462
      Courtesy92.395.294.195.8.026
      p < .05.
      .183
      Education and information67.172.971.874.7.005
      p < .05.
      .163
      Emotional support78.583.381.984.4.004
      p < .05.
      .131
      Patient preferences78.282.281.283.5.012
      p < .05.
      .132
      Visit coordination82.185.484.586.3.034
      p < .05.
      .243
      Specialist care78.281.481.782.6.088.644
      Abbreviations: MST, military sexual trauma; MST+, patients with a history of MST; MST−, patients without a history of MST.
      Adjusted mean scores derived from regression models using the following patient characteristics: Age, race, ethnicity, marital status, education, income, employment, VHA utilization in previous year, service connection, health status, Medicare, health insurance, and type of clinic visit.
      p < .05.
      Table 4 shows the unadjusted and adjusted mean scores for overall satisfaction and each dimension of satisfaction by MST screen status for women. Compared with women without a history of MST, women with a history of MST had lower unadjusted mean scores for the following dimensions of satisfaction: Overall coordination, access, courtesy, education and information, emotional support, patient preferences, and specialist care (p < .05). After adjusting for patient characteristics, the adjusted mean satisfaction scores for women with a history of MST were lower for the dimensions of overall coordination and education and information (p < .05).
      Table 4Unadjusted and Adjusted Mean Scores for Overall Satisfaction and Dimensions of Satisfaction Stratified by MST Status, Women (n = 5,758)
      Unadjusted ScoresAdjusted Scores
      Adjusted mean scores derived from regression models using the following patient characteristics: Age, race, ethnicity, marital status, education, income, employment, VHA utilization in previous year, service connection, health status, Medicare, health insurance, and type of clinic visit.
      p-Values for

      Differences by MST
      MST+MST−MST+MST−UnadjustedAdjusted
      Overall satisfaction69.773.182.582.2.256.888
      Overall coordination62.372.873.880.4<.0001
      p < .05.
      .006
      p < .05.
      Continuity78.481.280.382.2.301.509
      Access72.778.384.286.7.004
      p < .05.
      .195
      Courtesy90.293.494.595.9.050
      p < .05.
      .356
      Education and information62.670.769.776.1.001
      p < .05.
      .012
      p < .05.
      Emotional support76.281.981.885.8.006
      p < .05.
      .066
      Patient preferences76.981.382.185.0.023
      p < .05.
      .166
      Visit coordination79.781.684.084.9.326.636
      Specialist care73.378.878.482.5.021
      p < .05.
      .080
      Abbreviations: MST, military sexual trauma; MST+, patients with a history of MST; MST−, patients without a history of MST.
      Adjusted mean scores derived from regression models using the following patient characteristics: Age, race, ethnicity, marital status, education, income, employment, VHA utilization in previous year, service connection, health status, Medicare, health insurance, and type of clinic visit.
      p < .05.
      Differences in patient satisfaction as a function of MST were limited to the overall coordination and education and information subscales among women. To assess potential points of intervention for these subscales, we conducted a post hoc analysis among women patients, examining each item on the overall coordination and education and information subscales for its association with MST status. Results are displayed in Table 5. After controlling for patient characteristics, four items of the overall coordination dimension were significantly different between women who had a history of MST and those who did not. These items pertained to provider familiarity with their medical history, awareness of test results, awareness of changes in treatments owing to other providers’ recommendations, and confusion arising from receiving different information from different providers. After controlling for patient characteristics, four items of the education and information dimension were significantly different among women who had a history of MST and those who did not. These items included women identifying that the answers to questions, reasons for tests, results of tests, and side effects of prescribed medications were all explained by a provider in an understandable way.
      Table 5Unadjusted and Adjusted Mean Scores for Overall Coordination and Education and Information Subscale Items Stratified by MST Status, Women (n = 5,758)
      Unadjusted ScoresAdjusted Scores
      Adjusted mean scores derived from regression models using the following patient characteristics: Age, race, ethnicity, marital status, education, income, employment, VHA utilization in previous year, service connection, health status, Medicare, health insurance, and type of clinic visit.
      p-Values for

      Differences by MST
      MST+MST−MST+MST−UnadjustedAdjusted
      Overall coordination
       Provider familiar with your medical history57.168.469.776.7.001.016
      p < .05.
       Provider knows about other test results64.679.781.989.6<.0001.001
      p < .05.
       Provider knows about other doctor’s recommendation68.582.688.493.0.0001.014
      p < .05.
       Not confused because different providers told you different things71.882.888.591.8.0001.030
      p < .05.
       Always know your next step in care46.954.762.166.3.027.229
       Always know who to ask if you have questions56.065.566.371.9.005.087
      Education and information
       Answers to questions were always understandable66.476.078.883.9.002.043
      p < .05.
       Provider explained why you needed tests understandably69.278.678.084.1.006.044
      p < .05.
       Provider explained results of tests understandably54.268.463.274.9.002.008
      p < .05.
       Provider explained the purpose of prescribed medications understandably69.377.277.382.5.030.101
       Provider discussed side effects of any medications understandably45.457.849.059.8.003.016
      p < .05.
       Provider explained what to do if problems or symptoms continued, got worse, or came back52.760.961.366.1.395.221
       Provider gave as much information about your condition and/or treatment as you wanted55.662.167.370.8.048.273
      Abbreviations: MST, military sexual trauma; MST+, patients with a history of MST; MST−, patients without a history of MST.
      Adjusted mean scores derived from regression models using the following patient characteristics: Age, race, ethnicity, marital status, education, income, employment, VHA utilization in previous year, service connection, health status, Medicare, health insurance, and type of clinic visit.
      p < .05.

      Discussion

      Lower patient satisfaction is indicative of patients’ experiences with health care barriers, and there is a substantial literature on heath care barriers experienced by violence-exposed women. It has been noted that the high prevalence of MST among female patients requires VHA provider and staff sensitivity to the veterans’ care environment, particularly in terms of safety and comfort (
      • Yano E.M.
      • Hayes P.
      • Wright S.
      • Schnurr P.P.
      • Lipson L.
      • Bean-Mayberry B.
      • et al.
      Integration of women veterans into VA quality improvement research efforts: What researchers need to know.
      ). A large survey of U.S. women found that those who have experienced sexual violence report more difficulties obtaining needed care, more difficulties talking with their health care provider, and were more likely to have changed providers in the past year because they were dissatisfied, as compared with women who have not experienced violence (
      • Plichta S.B.
      • Falik M.
      Prevalence of violence and its implications for women’s health.
      ). Difficulties with patient provider communication among women exposed to interpersonal violence have also been found in other samples of health care users (
      • McCauley J.
      • Yurk R.A.
      • Jenckes M.W.
      • Ford D.E.
      Inside "Pandora’s box": Abused women’s experiences with clinicians and health services.
      ,
      • McNutt L.A.
      • van Ryn M.
      • Clark C.
      • Fraiser I.
      Partner violence and medical encounters: African-American women’s perspectives.
      ,
      • Monahan K.
      • Forgash C.
      Enhancing the health care experiences of adult female survivors of childhood sexual abuse.
      ).
      Despite these possible health care barriers, our results indicate that overall satisfaction among patients with a history of MST is relatively high, and does not significantly differ from patients who do not report a history of MST. After adjustment, almost all other dimensions of satisfaction were similar among patients with and without a history of MST, for both female and male outpatients. The lack of significant differences on other subscales may represent considerable success on the part of VHA in meeting the needs of MST patients, especially female patients. Since 1992, when the VHA was first authorized to provide MST-related counseling, the health care system has developed a comprehensive set of policies to detect and treat sexual trauma, train staff and providers about sexual trauma-related issues, and monitor and coordinate sexual trauma-related services. Emerging research suggests that these policies are feasible and have clinical benefit (
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.E.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      ,
      • Kimerling R.
      • Street A.E.
      • Gima K.
      • Smith M.W.
      Evaluation of universal screening for military-related sexual trauma.
      ).
      Furthermore, our results highlight the importance of adjusting for patient characteristics and disability when studying patient satisfaction. Factors such as age, race, education, and health status have demonstrated associations with patient satisfaction in previous studies of VHA and other health care systems (
      • Borowsky S.
      • Nelson D.
      • Fortney J.
      • Hedeen A.
      • Bradley J.
      • Chapko M.
      VA community-based outpatient clinics: Performance measures based on patient perceptions of care.
      ,
      • Crow R.
      • Gage H.
      • Hampson S.
      • Hart J.
      • Kimber A.
      • Storey L.
      • et al.
      The measurement of satisfaction with healthcare: Implications for practice from a systematic review of the literature.
      ,
      • Desai R.A.
      • Stefanovics E.A.
      • Rosenheck R.A.
      The role of psychiatric diagnosis in satisfaction with primary care: Data from the Department of Veterans Affairs.
      ,
      • Wright S.M.
      • Craig T.
      • Campbell S.
      • Schaefer J.
      • Humble C.
      Patient satisfaction of female and male users of Veterans Health Administration services.
      ). Unadjusted comparisons of patient satisfaction suggested that patients with histories of MST also report significantly lower levels of satisfaction with health care than patients without histories of MST. Our unadjusted results are similar to the one preliminary study of military sexual assault and patient satisfaction, which controlled for health status but not patient characteristics (
      • Kelly M.M.
      • Vogt D.S.
      • Scheiderer E.M.
      • Ouimette P.C.
      • Daley J.
      • Wolfe J.
      Effects of military trauma exposure on women veterans’ use and perceptions of Veterans Health Administration care.
      ). In our data, outpatients who were younger or those who had greater levels of disability (e.g., poor health status, service connected disability) tended to report lower levels of satisfaction. Patients with a history of MST were highly prevalent among these patient groups. VHA efforts to improve patient satisfaction may benefit from education about clinical issues, such as MST, that are common to subgroups of patients with lower satisfaction ratings.
      After adjusting for patient characteristics, the domains of satisfaction that differed as a function of MST status were overall coordination and education and information. This effect was observed only among women. These results are similar to a previous study of satisfaction with primary care services among VHA patients with mental health conditions, where these patients reported lower satisfaction ratings for domains of access and overall coordination (
      • Desai R.A.
      • Stefanovics E.A.
      • Rosenheck R.A.
      The role of psychiatric diagnosis in satisfaction with primary care: Data from the Department of Veterans Affairs.
      ). In recent years, the VHA has seen the emergence and implementation of effective models of care management for mental health conditions in primary care (
      • Oslin D.W.
      • Ross J.
      • Sayers S.
      • Murphy J.
      • Kane V.
      • Katz I.R.
      Screening, assessment, and management of depression in VA primary care clinics. The Behavioral Health Laboratory.
      ,
      • Smith J.L.
      • Williams Jr., J.W.
      • Owen R.R.
      • Rubenstein L.V.
      • Chaney E.
      Developing a national dissemination plan for collaborative care for depression: QUERI Series.
      ). These programs increase overall coordination and access to mental health services. Our findings may underscore the importance of care coordination for women patients in mental health settings, where MST is highly prevalent (
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.E.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      ,
      • Valdez C.
      • Kimerling R.
      • Hyun J.
      • Mark H.
      • Saweikis M.
      • Pavao J.
      VHA mental health treatment settings of patients who report military sexual trauma.
      ). Post hoc analyses indicated that the specific items of the overall coordination dimension that were related to a history of MST were a provider’s familiarity with a patient’s medical history, awareness of patient’s tests results and changes in treatments owing to other provider recommendations, and confusion regarding different providers telling the patient different things. Thus, issues related to patients seeing multiple providers or engaged in multiple types of treatment are highlighted. These issues are likely to be important to MST patients, who tend to have complex medical and psychiatric comorbidities, and may especially benefit from such interventions. There may also be a benefit in addressing MST-related issues among female patients in VHA mental health care management programs. These results could also suggest that there is a need to educate providers about how MST screen results can be more comprehensively integrated into communication and treatment planning with women patients. Although all VHA patients may benefit from greater attention to care coordination, these issues seem to be particularly salient for patients with a history of MST.
      The items of the education and information subscale that significantly differentiated women by MST status were related to feelings that questions were answered and that reasons for and results of tests, as well as side effects of prescribed medications, were all well explained by a provider. These items highlight the need for clear communication between providers and women with a history of MST. These findings are consistent with previous research among women with a history of interpersonal violence that has shown that these women reported lower ratings of quality of communication with their providers (
      • McNutt L.A.
      • van Ryn M.
      • Clark C.
      • Fraiser I.
      Partner violence and medical encounters: African-American women’s perspectives.
      ), difficulty talking with a provider, and feeling too embarrassed to discuss a medical problem with a provider (
      • Plichta S.B.
      • Falik M.
      Prevalence of violence and its implications for women’s health.
      ). These findings underscore how patient self-efficacy education as part of or in addition to regular care at the VHA may be especially beneficial for women veterans with histories of MST.
      Several limitations should be considered in the interpretation of these results. We were able to measure satisfaction with VHA care among patients who reported MST, but we did not measure satisfaction with specific MST-related mental health services. Additionally, we were unable to measure other types of non-military sexual trauma which may have an effect on ratings of patient satisfaction with VHA care among both groups. These are important areas for future investigations. The few differences this study did find between patients with and without histories of MST may be slightly conservative estimates, because there may be some undetected MST among patients with negative screens. Despite these limitations, these data do represent the first national study of satisfaction with VHA care among men and women who report MST. The study also contained several methodological strengths, such as representative sampling and adjustment for relevant demographic and service utilization characteristics. As a representative sample of VHA patients nationally, the greatest proportion of men with a history of MST was above 55 years old. Our sample size did not permit analyses stratified by age or other relevant patient characteristics. Future studies focusing on age and other important variables, such as time since the MST experience and the current subjective levels of distress resulting from the MST experience, would be valuable.
      In summary, the high satisfaction ratings and few differences associated with MST status found in this study may be due to the increasing emphasis in VHA on provider training, outreach, and awareness of MST-related health care issues. Providers and MST coordinators at each facility are offered ongoing opportunities for clinical training and continuing education. National resources are available to facilitate local training on MST-related issues at each facility. These educational efforts have been accompanied by regular monitoring of both MST-related screening and treatment, as well as patient perceptions of quality, enabling timely, ongoing feedback in both domains. Continued focus on both patient satisfaction and clinical care for MST are essential to maintaining the VHA’s standards of high-quality, patient-centered care. The present study is the first to provide preliminary evidence for satisfaction with VHA health care among patients who report MST.

      Acknowledgments

      This material is the result of work supported with resources and the use of facilities at the National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
      Dr. Kimerling had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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      Biography

      Rachel Kimerling is a Clinical Psychologist at the National Center for Posttraumatic Stress Disorder, Dissemination and Training Division and an Investigator at the Center for Health Care Evaluation, VA Palo Alto Health Care System. She specializes in sexual trauma research.
      Joanne Pavao is a Health Science Specialist at the National Center for Posttraumatic Stress Disorder, Dissemination and Training Division at VA Palo Alto Healthcare System. Her research interests include the effects of interpersonal violence including intimate partner violence and sexual assault.
      Courtney Valdez is a Clinical Psychologist at the San Francisco Vet Center, treating Veterans who are struggling with readjustment issues and have experienced combat and/or military sexual trauma (MST).
      Hanna Mark is a Research Health Science Specialist at the National Center for Posttraumatic Stress Disorder, Dissemination and Training Division at VA Palo Alto Healthcare System. Her research interests lie in the mental health effects of gendered and sexual violence.
      Jenny K. Hyun is a Health Science Specialist at the National Center for Posttraumatic Stress Disorder, Dissemination and Training Division at VA Palo Alto Healthcare System. Her current research interests are in organizational research, women veterans, and military sexual trauma.
      Meghan Saweikis is a Health Science Specialist at the National Center for Posttraumatic Stress Disorder, Dissemination and Training Division at VA Palo Alto Healthcare System. Her research interests are in Veterans’ mental health and effective use of large-scale datasets.