This cross-sectional, quality improvement study was conducted at a single large, urban VA. Approved by the institutional review board as a quality improvement initiative, this study employed a telephone-based survey administered to veterans referred from the Jesse Brown VA Heart Center in Chicago, IL, to non-VA community hospitals for structural heart procedures between 2018 and 2023. Eligible participants were identified through institutional referral records and included veterans who underwent transcatheter aortic valve replacement (TAVR) or other interventions for structural heart disease under MISSION Act-authorized community care referrals. All surviving patients meeting the inclusion criteria were called and invited to complete the survey voluntarily, with responses recorded after receiving informed consent. Data collection occurred from August 2024 to February 2025.

Of the 167 patients identified through referral records, 69 had passed away before the data collection period. Veterans unavailable during the initial call attempt were recontacted once before being classified as unreachable. Of the remaining 98 veterans, 46 remained unreachable, and 5 declined participation. Only veterans who directly received care were surveyed; caregivers were not included as independent respondents. In cases where a caregiver assisted during the call (e.g., to facilitate communication), all survey responses were provided by the veteran themselves. Ultimately, 47 veterans completed the full telephone survey and were included in the final analysis.

The survey instrument was designed to assess veterans’ satisfaction with the care they received and their preferences for future healthcare delivery based on questions adapted from the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient Experiences Survey. It consisted of 14 items grouped into the domains of: Community Care Experience, Communication, Quality of Care, Care Coordination, Barriers to Care, Global Satisfaction, and Preferences for Future Healthcare (Appendix A). Preferences for future care were assessed for both cardiovascular care and general healthcare. For the purposes of this study, ‘general healthcare’ was defined as primary and nonspecialty care services, including routine visits, preventive care, and management of chronic medical conditions.

Satisfaction with quality indicators was scored on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Overall satisfaction with VA and Community Care scores was scored on a 10-point Likert Scale. Demographic and clinical variables were obtained through chart review.

Descriptive statistics were calculated for all variables. Continuous variables were summarized using means and standard deviations, while categorical variables were summarized using frequencies and percentages. Group differences in preference (VA vs. community) were assessed using t-tests or one-way ANOVA for continuous variables, and chi-square or Fisher’s exact tests for categorical variables. Binomial tests were used to assess whether preferences significantly differed from equal distribution. Pearson correlation coefficients were calculated to assess associations between satisfaction scores (Q11 and Q12) and Likert subdomain responses. A 2-sided P -value <.05 was considered statistically significant. Analyses were conducted using R version 4.2.2. The primary outcome studied was patient preference for future site for receiving care—VA vs. community. Secondary outcomes included overall satisfaction, satisfaction scores across care domains, correlation with demographic variables, and predictors of global satisfaction with care across sites.

Baseline characteristics of the cohort can be seen in Table 1 . A total of 47 veterans who met the inclusion criteria completed the survey. All respondents were males, and the mean age was 78.4 (± 9.90) years. 63.8% of respondents identified as white, and 34% black. Comorbid chronic diseases were common amongst the cohort; about 91% of respondents were diagnosed with hypertension, 57% with type 2 diabetes mellitus, 30% with chronic kidney disease, 55% with coronary artery disease, and 45% with heart failure. The majority (81%) were referred to community care for transcatheter aortic valve replacement (TAVR), while 19% were referred for another structural heart disease intervention. About 83% were referred because their VA could not perform the necessary intervention, 9% were referred due to distance traveled, and 6% due to personal preference. Only 10.6% of veterans reported receiving other healthcare outside of the VA.

Mean satisfaction scores reported on a 1-10 Likert scale (10 being highest) for the entire cohort were relatively high for both community care (9.15) and the VA-based care (9.19), and not significantly different ( P =.876). 64% of veterans ( n = 30) preferred receiving future cardiovascular care at the VA hospital ( P =.079). For general healthcare, veterans expressed a statistically significant preference for the VA, with 78.7% preferring the VA hospital, compared to 19.1% who preferred a community hospital ( P <.001) ( Table 2 ).

A total of 9 questions were asked to assess specific factors impacting satisfaction with referrals, grouped into 3 domains: Communication, Quality of Care , and Care Coordination . Communication items assessed the clarity of referral information (Q1), patients’ feeling well-informed about procedures (Q2), and adequacy of follow-up instructions (Q3). Quality of Care items evaluated satisfaction with facilities (Q4), staff competence (Q5), and whether veterans felt their concerns and preferences were heard (Q6). Care Coordination items assess the coordination between VA and community providers (Q7), timeliness of scheduling (Q8), and reliability of transportation arrangements (Q9).

The mean response of all 9 quality indicators was above 4.6 for the entire cohort ( Table 2 ). Satisfaction with community care was strongly correlated with several quality domains. The strongest associations were with satisfaction with staff competence ( r = 0.839), feeling that concerns and preferences were heard ( r = 0.818), and coordination between VA and community providers ( r = 0.778) ( Table 3 ). Satisfaction with VA care was most strongly associated with satisfaction with coordination between VA and community providers ( r = 0.789), clear follow-up instructions ( r = 0.729), and timeliness of scheduling ( r = 0.681) ( Table 4 ).

Table 4

Correlation with quality variables and satisfaction with VA care (Q12)

Survey question	correlation Coefficient	P -value	95% CI lower	95% CI upper
Communications (1-5)
Q1: Clear information	0.505	<.001	0.247	0.696
Q2: Well informed	0.373	<.001	0.088	0.602
Q3: Follow-up	0.729	.001	0.554	0.843
Quality of care (1-5)
Q4: Care facilities	0.412	.004	0.133	0.63
Q5: Staff competence	0.510	<.001	0.253	0.699
Q6: Concerns heard	0.635	<.001	0.418	0.783
Coordination (1-5)
Q7: Coordination	0.789	<.001	0.644	0.879
Q8: Minimal delays	0.681	<.001	0.483	0.812
Q9: Transportation	0.16	.283	−0.141	0.434

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