VA Primary Care Research Articles

The Nature and Prevalence of Patient Expectations in a VA General Medicine Clinic

PURPOSE: Patients' expectations influence clinicians' prescribing and referral behaviors, yet little is known about their specific expectations for care. We conducted this study to describe the nature, prevalence and fulfillment of expectations patients present to their clinicians and their relationship to satisfaction. METHODS: Subjects were recruited from a random sample of patients visiting a VA general medicine outpatient clinic. Interviewers administered a face-to-face, structured questionnaire designed to assess patients' expectations before the visit. Afterwards, patients identified the services they received and rated their satisfaction with the visit using the ABIM Patient Satisfaction Questionnaire (PSQ) and Ware Visit Specific Questionnaire (VSQ). RESULTS: We approached 401 patients, of whom 253 (63%) completed both the pre- and post-visit interviews. The remaining 148 patients either refused (16%), did not complete the interview (21%), or were unable to understand the questions (<1%). The median age was 65; 68% were white and the majority had completed high school. 31% of patients reported one expectation and 25% had two or more expectations. Patients' expectations were extremely varied, falling into 40 different categories of tests, referrals, and new medications, and many were vague, as 40% could not be categorized. 50% of patients who expressed an expectation did not receive their desired service. Nevertheless, patient satisfaction was high. Median scores on the VSQ and PSQ respectively were 1.5 and 1.0 (1 = excellent, 5 = poor). Patients with one or more unmet expectations did not differ significantly from patients with all expectations met on the VSQ and PSQ (p = .308 and p = .502, respectively). Only patients who expected a new medication but did not receive it reported lower levels of satisfaction (p = .002). CONCLUSION: Patients present to VA primary care providers with multiple and varied expectations for tests, referrals, and new medications, and many of these expectations are not met. However, patient satisfaction remains high and is largely unrelated to fulfillment of expectations. Further research should examine attributes of the clinical encounter that result in high satisfaction despite unmet expectations.

Detection and treatment of depression in a VA primary care clinic.

The Veterans Health Administration clinical guideline for major depressive disorder was used in screening 574 male veterans treated in primary care settings in the Department of Veterans Affairs health care system. Thirteen percent (N=73) screened positive for depression, and 33 percent of those patients showed evidence of a major depressive episode. Pre- and posttreatment assessment of a sample of 16 patients treated for depression in a primary care setting revealed statistically significant improvement with treatment.

Cognitive Dysfunction and Disability in Geriatric Veterans with Self-Reported Intolerance to Environmental Chemicals

AbstractThe symptom of sensitivity or intolerance to low ley-els of environmental chemicals (CI) is a characteristic of several clinical conditions, such as multiple chemical sensitivity (MCS), chronic fatigue syndrome (CFS), fibromyalgia (FM), and the “Persian Gulf Syndrome.” Lesser degrees of CI also occur in 15-30% of non-clinical populations. The present study examined the prevalence and concomitant health patterns of CI in elderly veterans in a VA primary care medical clinic (N = 160, primarily men). Thirty-seven percent of the sample endorsed the screening question asking whether or not they considered themselves “especially sensitive to certain chemicals.” The group with CI reported a significantly higher rate of physical disability and increased susceptibility to becoming sick. The CI group reported significantly decreased rates of current cigarette smoking and alcohol use. Those with and those without CI did not differ in level of depression or in past occupational chemical exposures. However, th...