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. 2023 Dec 1;6(12):e2348235.
doi: 10.1001/jamanetworkopen.2023.48235.

Disparities in Preoperative Goals of Care Documentation in Veterans

Adela Wu  1   2 , Karleen F Giannitrapani  1   3 , Ariadna Garcia  1   4 , Selen Bozkurt  1   5 , Derek Boothroyd  1   4 , Alyce S Adams  6 , Kyung Mi Kim  1   7 , Shiqi Zhang  1   4 , Matthew D McCaa  1 , Arden M Morris  8   9 , Scott Shreve  10   11 , Karl A Lorenz  1   3
Affiliations

Disparities in Preoperative Goals of Care Documentation in Veterans

Adela Wu et al. JAMA Netw Open. .

Abstract

Importance: Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk.

Objective: 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.

Exposures: Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors.

Main outcomes and measures: 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.

Results: 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).

Conclusions and relevance: 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Lorenz reported operational funding from the Department of Veterans Affairs during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart of Cohort
LST indicates life-sustaining treatment.
Figure 2.
Figure 2.. Odds Ratios (ORs) of Select Factors on Preoperative Life-Sustaining Treatment Documentation for Veterans
CAN indicates care assessment need score; CCI, Charlson Comorbidity Index; ESKD, end-stage kidney disease.
See this image and copyright information in PMC

References

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