Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California.
Office of Research Patient Care Services, Stanford Health Care, Palo Alto, California.
JAMA Netw Open. 2023 Feb 1;6(2):e2255407. doi: 10.1001/jamanetworkopen.2022.55407.
Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery.
To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022.
Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more.
Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation.
Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47).
Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.
重要性：与患者讨论目标以及计划中的和潜在的治疗方案是预先护理计划的核心。进行或确认预先护理计划对于术前准备也至关重要，尤其是在体弱或接受高危手术的患者中。
目的：评估患者住院或死亡风险与接受手术的退伍军人中记录在生命维持治疗（LST）决策倡议说明中的目标关怀对话之间的关联。
设计、设置和参与者：这是一项回顾性的横断面研究，包括 190400 名于 2017 年 1 月 1 日至 2020 年 2 月 28 日期间接受手术的退伍军人。统计分析于 2021 年 11 月 1 日至 2022 年 11 月 17 日进行。
暴露：患者的住院或死亡风险，使用护理评估需求（CAN）评分（范围为 0-99，得分越高表示住院或死亡的风险越高）进行评估，分为小于 80 或 80 或更高。
主要结果和措施：术前 LST 说明的完成（手术前 30 天或手术当天）或在手术前 30 天内未完成 LST 说明。
结果：在 190400 名退伍军人中（90.8%为男性；平均[标准差]年龄 65.2[11.9]岁），3.8%的人在手术前完成了 LST 说明，96.2%的人没有完成 LST 说明。在有和没有术前完成 LST 说明的组中，大多数人的年龄在 65 至 84 岁之间（62.1%对 56.7%）、男性（94.3%对 90.7%）和白人（82.2%对 78.3%）。与术前完成 LST 说明的患者相比，术前未完成 LST 说明的患者更可能为女性（9.3%对 5.7%）、黑人（19.2%对 15.7%）、已婚（50.2%对 46.5%）和健康状况较好（Charlson 合并症指数评分为 0 的患者占 25.9%对 15.2%）；住院或死亡风险较低（CAN 评分<80 的患者占 98.3%对 96.9%）；或接受神经外科（9.8%对 6.2%）或泌尿科手术（5.9%对 2.0%）。在 3 年的时间间隔内，术前完成 LST 说明的未调整率从 0.1%增加到 9.6%。协变量调整后的 LST 说明完成估计表明，与 CAN 评分小于 80 的患者相比，住院或死亡风险相对较高（CAN 评分≥80）的退伍军人更有可能在术前完成 LST 说明（比值比[OR]，1.29；95%置信区间[CI]，1.09-1.53）。高危手术与术前 LST 说明的增加无关（OR，0.93；95%CI，0.86-1.01）。接受心胸外科手术的退伍军人最有可能在术前完成 LST 说明（OR，1.35；95%CI，1.24-1.47）。
结论和相关性：尽管 LST 说明的实施有所增加，但少数退伍军人在术前完成了 LST 说明。尽管与低风险患者相比，高风险患者更有可能这样做，但需要改善积极的沟通和目标的记录，特别是在高风险的退伍军人中。这样做可能会促进目标一致的手术护理和结果。
