VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California.
Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
JAMA Netw Open. 2023 Dec 1;6(12):e2348235. doi: 10.1001/jamanetworkopen.2023.48235.
Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk.
To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022.
Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors.
Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression.
In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001).
In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.
术前目标护理讨论和记录对于接受手术的患者非常重要，这是一个主要的医疗保健压力源，会带来风险。
评估种族、民族和其他因素（包括心理健康障碍史）与退伍军人术前目标护理记录的差异之间的关联。
设计、设置和参与者：这项回顾性横断面研究评估了退伍军人医疗保健管理局（VHA） 2017 年 1 月 1 日至 2022 年 10 月 18 日期间接受手术的 229737 名退伍军人的数据。
患者层面（即种族、民族、医疗合并症、心理健康合并症史）和系统层面（即设施复杂程度水平）因素。
术前维持生命治疗（LST）记录或手术前 30 天内或手术当天无 LST 记录。计算标准化均数差异以评估组间差异的大小。使用逻辑回归估计比值比（OR）和 95%置信区间。
在这项研究中，从 229737 名 VHA 患者（209123 [91.0%] 男性；20614 [9.0%] 女性；平均[标准差]年龄，65.5[11.9]岁）中，有 13408 名患者（5.8%）完成了术前 LST。与完成术前 LST 的患者相比，如果患者为女性（19914 [9.2%] 与 700 [5.2%]）、黑人（42571 [19.7%] 与 2416 [18.0%]）、西班牙裔（11793 [5.5%] 与 631 [4.7%]）或来自农村地区（75637 [35.0%] 与 4273 [31.9%]），他们更有可能不太经常完成术前记录；有心理健康障碍史（65974 [30.5%] 与 4053 [30.2%]）；或在最低复杂程度（即 3 级）设施就诊（7849 [3.6%] 与 78 [0.6%]）。尽管发生了 COVID-19 大流行，但随着时间的推移，接受手术的患者越来越多地完成了术前 LST。调整了协变量的术前 LST 完成率估计值表明，少数民族背景（黑人患者：OR，0.79；95%置信区间，0.77-0.80；P<.001；选择其他种族的患者：OR，0.78；95%置信区间，0.74-0.81；P<.001；西班牙裔患者：OR，0.78；95%置信区间，0.76-0.81；P<.001）和农村地区的患者（OR，0.91；95%置信区间，0.90-0.93；P<.001）完成 LST 的可能性低于白人或非西班牙裔患者和来自城市地区的患者。有任何心理健康障碍史的患者完成术前 LST 的可能性也低于没有病史的患者（OR，0.93；95%置信区间，0.92-0.94；P=0.001）。
在这项横断面研究中，根据种族、民族、患者居住地的农村性、心理健康障碍史以及获得高容量、高复杂性设施的机会，退伍军人队列中仍然存在记录率的差异。
