A Triangulated Qualitative Study of Veteran Decision-Making to Seek Care During Heart Failure Exacerbation: Implications of Dual Health System Use

Inquiry. 2018 Jan-Dec:55:46958017751506. doi: 10.1177/0046958017751506.


Among Veterans, heart failure (HF) contributes to frequent emergency department visits and hospitalization. Dual health care system use (dual use) occurs when Veterans Health Administration (VA) enrollees also receive care from non-VA sources. Mounting evidence suggests that dual use decreases efficiency and patient safety. This qualitative study used constructivist grounded theory and content analysis to examine decision making among 25 Veterans with HF, for similarities and differences between all-VA users and dual users. In general, all-VA users praised specific VA providers, called services helpful, and expressed positive capacity for managing HF. In addition, several Veterans who described inadvertent one-time non-VA health care utilization in emergent situations more closely mirrored all-VA users. By contrast, committed dual users more often reported unmet needs, nonresponse to VA requests, and faster services in non-VA facilities. However, a primary trigger for dual use was VA telephone referral for escalating symptoms, instead of care coordination or primary/specialty care problem-solving.

Keywords: Veterans; decision making; dual use; heart failure; qualitative research.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Decision Making*
  • Female
  • Heart Failure / therapy*
  • Humans
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / psychology*
  • Primary Health Care / organization & administration
  • Qualitative Research
  • Quality of Health Care / organization & administration
  • Referral and Consultation / organization & administration
  • Time Factors
  • United States
  • United States Department of Veterans Affairs / organization & administration*
  • Veterans / psychology*