Gender and Patient Satisfaction in a Veterans Health Administration Outpatient Chemotherapy Unit
Background: Our objective was to explore whether differences in patient satisfaction based on gender exist at the Veterans Affairs Portland Health Care System (VAPHCS) outpatient chemotherapy infusion unit.
Methods: Veterans who received outpatient infusion treatments at the VAPHCS outpatient chemotherapy infusion unit from 2018 to 2020 were invited to take an anonymous survey. Response differences were analyzed using Fisher exact and Welch t tests. Male and female patient lists were first generated based on Computerized Patient Record System designation, then defined and results reported based on gender self-identification from survey responses.
Results: The survey was conducted over a 2-week period during January and February of 2021. In total, 69 veterans were contacted: 21 (70%) of 30 female and 20 (51%) of 39 male veterans completed the survey. Most (62%) female patients were aged < 65 years, and 52% were treated for breast cancer. Most (90%) male patients were aged ≥ 65 years, and most commonly treated for prostate cancer (20%) or a hematologic malignancy (20%). Using our survey, patient satisfaction (SD) was 8.7 (2.2) on a 10-point scale among women, and 9.6 (0.6) among men (P = .11). History of sexual abuse or harassment was reported by 86% of women compared with 10% of men (P < .001). Women reported feeling uncomfortable around other patients in the infusion unit compared with men (29% vs 0%; P = .02) and discomfort in relaying uncomfortable feelings to a clinician (29% vs 0%; P = .02).
Conclusions: Gender seems to be related to how veterans with cancer perceive their ambulatory cancer care. This may be due to the combination of a high history of sexual abuse and/or harassment among women who represent a minority of the total infusion unit population, the majority of whom receive treatment for a primarily gender-specific breast malignancy. Analysis was limited by the small sample size of women, many with advanced malignancy.
Ten (48%) women and 6 (30%) men reported emotional support when receiving treatments provided by staff of the same gender (P = .34). Eight (38%) women and 4 (20%) men noted that access to treatment with the same gender was important (P = .31). Six (29%) women and 4 (20%) men indicated that access to a sex or gender-specific restroom was important (P = .72). No gender preferences were identified in the survey questions regarding importance of private treatment room access and level of emotional support when receiving treatment with others of the same malignancy. These relationships were not statistically significant.
In addition, 2 open-ended questions were asked. Seventeen women and 14 men responded. Contact the corresponding author for more information on the questions and responses.
Discussion
Overall patient satisfaction was high among the men and women veterans with cancer who received treatment in our outpatient infusion unit; however, notable gender differences existed. Three items in the survey revealed statistically significant differences in the patient experience between men and women veterans: history of sexual abuse or harassment, uncomfortable feelings among other patients, and discomfort in relaying uncomfortable feelings to a clinician. Other items in the survey did not reach statistical significance; however, we have included discussion of the findings as they may highlight important trends and be of clinical significance.
We suspect differences among genders in patient satisfaction to be related to the high incidence of sexual abuse or harassment history reported by women, much higher at 86% than the one-third to one-fourth incidence rates estimated by the existing literature for civilian or military sexual abuse in women.5,6 These high sexual abuse or harassment rates are present in a majority of women who receive cancer-directed treatment toward a gender-specific breast malignancy, surrounded predominantly among men in a shared treatment space. Together, these factors are likely key reasons behind the differences in satisfaction observed. This sentiment is expressed in our cohort, where one-fifth of women with a sexual abuse or harassment history continue to remain uncomfortable around men, and 29% of women reporting some uncomfortable feelings during their treatment experience compared with none of the men. Additionally, 6 (29%) women vs no men felt uncomfortable in reporting an uncomfortable experience with a clinician; this represents a significant barrier in providing care for these patients.
A key gender preference among women included access to shared treatment rooms with other women and that sharing a treatment space with other women resulted in feeling more emotional support during treatments. Access to gender-specific restrooms was also preferred by women more than men. Key findings in both genders were that about half of men and women valued access to a private treatment room and would derive more emotional support when surrounded by others with the same cancer.
Prior studies on gender and patient satisfaction in general medical care and cancer care have found women value privacy more than men.1-3 Wessels and colleagues performed an analysis of 386 patients with cancer in Europe and found gender to be the strongest influence in patient preferences within cancer care. Specifically, the highest statically significant association in care preferences among women included privacy, support/counseling/rehabilitation access, and decreased wait times.2 These findings were most pronounced in those with breast cancer compared with other malignancy type and highlights that malignancy type and gender predominance impact care satisfaction.
Traditionally a shared treatment space design has been used in outpatient chemotherapy units, similar to the design of the VAPHCS. However, recent data report on the patient preference for a private treatment space, which was especially prominent among women and those receiving longer infusions.7 In another study that evaluated 225 patients with cancer preferences in sharing a treatment space with those of a different sexual orientation or gender identify, differences were found. Both men and women had a similar level of comfort in sharing a treatment room with someone of a different sexual orientation; however, more women reported discomfort in sharing a treatment space with a transgender woman compared with men who felt more comfortable sharing a space with a transgender man.4 We noted a gender preference may be present to explain the difference. Within our cohort, women valued access to treatment with other women and derived more emotional support when with other women; however, we did not inquire about feelings in sharing a treatment space among transgender individuals or differing sexual orientation.
