Veteran voices on the MISSION act: Satisfaction and care preferences following community referral for structural heart disease care

Abstract: BACKGROUND: The MISSION Act of 2018 expanded veterans' access to necessary care at non-Veterans Affairs (VA) facilities. The policy is intended to improve access to timely, high-quality care-particularly for specialized procedures like transcatheter aortic valve replacement (TAVR). However, veterans' preferences regarding specialty care in the community vs within the VA system remain unexplored. METHODS: This cross-sectional quality improvement study surveyed veterans at an urban VA heart center who received referrals to community hospitals between 2018 and 2023 for structural heart disease care. The 14-item survey evaluated satisfaction across 3 key domains-communication, quality, and care coordination-along with overall satisfaction with community and VA care, and preferences for future care delivery settings. RESULTS: Of 47 veterans who completed the survey, most (78.7%) preferred receiving care at a VA hospital (P < .0001). Veterans reported high satisfaction with both community (mean score 9.15/10) and VA-based care (9.19/10; P = .876). While 64% preferred the VA for future cardiovascular care, this trend did not reach statistical significance (P = .079). In contrast, 78.7% preferred the VA for general healthcare (P < .001). Satisfaction with community care was most strongly associated with staff competence (r = 0.839) and feeling their concerns were heard (r = 0.818). VA satisfaction correlated most strongly with care coordination (r = 0.789) and clear follow-up instructions (r = 0.729). Transportation challenges were reported by 17% of respondents and were significantly associated with preference for community care for general health (P < .001). CONCLUSIONS: Veterans referred for cardiovascular procedures through the MISSION Act reported high satisfaction across settings but expressed a clear preference for VA-based care for general healthcare. These findings suggest that while community care is a valuable tool for improving access, investments in VA-based services remain critical to meeting veteran expectations and preserving care quality.