The VA is a model system that actively measures both the clinical and patient-centered quality of care of its user population.19
A recent report in this journal found that although women constitute a small percentage of the user population, the quality of ambulatory care is equivalent for women and men on numerous clinical measures.20
Patient satisfaction is an explicit patient-centered goal of the VA and our study shows that after adjustment for patient attributes, females report similar scores as males on most dimensions of outpatient satisfaction.
This study found that adjusting for demographic characteristics was essential to studying gender differences in satisfaction with VA care. Bivariate analyses confirmed significant gender differences in a wide range of demographic and health status attributes, most of which were significantly related to satisfaction scores. Our unadjusted findings indicated that men were significantly more satisfied on all satisfaction dimensions for both inpatients and outpatients. After adjustment for these attributes, most of these gender-related differences in satisfaction disappeared or became smaller. The attributes most prevalent in females that resulted in more favorable adjusted satisfaction scores were younger age, service connected status, being black, and discharged from psychiatry bedsection. These attributes were associated with lower satisfaction, particularly age, where over 40% of female veterans are under age 50 compared with approximately 8% of males. In contrast, the greater prevalence of better health status among females (significantly associated with higher satisfaction) resulted in less favorable adjusted satisfaction scores in women compared with men. The net effect of all the covariates substantially altered the unadjusted satisfaction scores.
Our finding that ratings of satisfaction were higher for veterans receiving outpatient versus inpatient care on similar measures of satisfaction for both genders may be due to the different nature and quality of services provided in these care settings and/or the differences in the demographic and health-related characteristics of the user populations. Not surprisingly, hospitalized patients were older and sicker than outpatient users. Inpatients also differed significantly on other important sociodemographic attributes such as race, income, employment status, marital status, and VHA priority status. Many of these attributes were associated with OQ and other dimensions of satisfaction, which could partly explain higher satisfaction scores reported by outpatients.
Another contrast between inpatient and outpatient findings was the fact that, after adjustment, among outpatients there was only 1 significant gender-related difference (Continuity of Care) (women were more satisfied than men). In contrast, for inpatients even after adjustment, scores for 6 dimensions of satisfaction (Transition, Physical Comfort, Involvement of Family and Friends, Courtesy, Coordination, and Access) remained significantly higher among men. While the absolute magnitude of these differences was approximately 4% or less, these findings need to be further examined to determine whether they reflect a true gender difference in quality of care received or are more related to the perception of care among women in the gender minority on inpatient units. It may be, for example, that the outpatient setting is less conducive to the perception of being in the minority, especially as many VHA facilities have provided outpatient care in specialized women's clinics, which an earlier study found to be preferable to women than standard clinic care.21
In contrast, virtually all VHA inpatient units are of mixed gender, with women comprising a small proportion of the patients on any unit. In such a situation, the experience of being in the minority may be much more apparent and may affect ratings of satisfaction. In addition, as noted in earlier reports,10, 11
these findings may reflect differences in the relative importance attached to these dimensions of care by men versus women.
Many of the demographic covariates (e.g., age, race, income, and education) used in this study have been shown to be associated with patient satisfaction in other studies.17, 22, 23
Other studies have demonstrated the important link between satisfaction and health status.24–26
In this study, we identified additional health-related factors in both outpatient and inpatient populations that are associated with satisfaction such as type of outpatient care, discharging hospital service, prior utilization, and insurance coverage. These findings suggest that future studies of satisfaction may need to adjust for a broader range of variables rather than the relatively narrow range of such variables used in past studies.
A limitation of this study is that it does not include facility or organizational characteristics known to influence patient satisfaction such as facility size, location, and organizational culture.28
The extent to which these characteristics mediate the effect of gender on satisfaction is unknown and should be the subject of additional research. Because of the disproportionate low number of women served by the VHA, our findings may not be generalizable to nonveteran populations. Survey of Healthcare Experiences of Patients is also different from other national surveys such as Consumer Assessment of Health Plan Study (CAHPS).4
The latter targets enrolled populations rather than users of health care. In addition, the findings of this study are based on patient's perceptions of quality, not technical quality. An important next step is to compare patients' rating of quality with clinical measures of quality to determine the extent to which satisfaction scores are associated with the actual quality of care or provide a unique patient-centered rating of care.