Disparities in Preoperative Goals of Care Documentation in Veterans

Key Points Question What factors, including race, ethnicity, rurality of residence, and Veterans Affairs (VA) facility complexity level, are associated with disparities in veterans completing preoperative life-sustaining treatment (LST) documentation? Findings In this cross-sectional study of 13 408 patients, few patients undergoing surgical procedures completed preoperative LST, with disparities in documentation rates based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume facilities within a VA cohort. Meaning These findings suggest that there is continued need for interventions that target patient groups at risk, namely racial or ethnic minority groups and those with history of mental health conditions, of missing opportunities to engage in serious illness communication.


Introduction
Surgery is a significant health care occurrence that should prompt timely goals of care (GOC)   planning and discussions about current personal values, goals, and treatment preferences.Best practices guidelines from the American College of Surgeons and the American Geriatrics Society recommend GOC discussion and documentation by health care clinicians, including surgeons, in case patients may not be able to make their own medical decisions. 1However, rates of GOC discussion and documentation are poor, and only 6.1% of preoperative consultations included the discussion of treatment preferences and goals for those undergoing high risk surgery, despite surgeons upholding the importance of preoperative GOC planning. 2reover, inadequate GOC documentation serves to amplify existing health care disparities.
Patients identifying as Hispanic, Asian, and Black have been found to be significantly less likely to have discussions with their health care clinicians and to have documented directives. 3,4A observational study focused on patients older than 65 years in California also demonstrated that male patients and those who spoke non-English preferred languages were significantly less likely to complete GOC discussion and documentation. 5om 2017, the Veterans Health Administration (VHA) has piloted and coordinated the Life-Sustaining Treatment (LST) Decisions Initiative (LSTDI) to encourage GOC discussion and documentation.The LSTDI is an effort to engage health care clinicians and patients in discussing and documenting patients' wishes and preferences regarding various medical treatments for prolonging life and designation of surrogate decision makers.Since the national implementation of the LSTDI in July 2018 until February 2020, only 3.8% of VHA patients undergoing surgical procedures had completed LST documentation by the time of their surgery despite recommendations to conduct the LST process for seriously ill patients at risk for life-threatening events. 6is study was informed by the conceptual framework of access to health care from Levesque et al 7 as well as published literature on health care services delivery within the VHA system. 8Thus, we performed a cross-sectional study and selected known or hypothesized factors associated with disparities in GOC discussion and LST documentation for VHA patients undergoing surgical procedures.While the LSTDI had relatively low implementation rates at the outset, we aimed to study populations at risk or characteristics associated with differences in preoperative access and documentation of GOC. 6 Thus, the goals for our investigation were to (1) investigate potential disparities in preoperative LST documentation based on patient's racial or ethnic background and health conditions; (2) identify patient-level and system-level associations with preoperative LST documentation; and (3) describe the COVID-19 pandemic's association with the completion of preoperative LST.We hypothesized that patients undergoing surgical procedures from minority backgrounds and patients with vulnerabilities, such as a history of mental health disability, would be at risk of missing opportunities to engage in preoperative GOC planning and LST documentation.

Methods
The cross-sectional study was approved by the joint Veterans Affairs (VA) Palo Alto Healthcare System and Stanford University institutional review board (IRB).A waiver of study participant consent was obtained from the IRB committee because patient data were deidentified and publicly available and the study was deemed minimal risk.The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.We included all veterans who underwent at least 1 surgical procedure between January 1, 2017, and October 18, 2022, in the VHA and were using VHA services for at least 1 year prior to their surgical procedure.

Data Source
To construct our cohort, we obtained data from the VA Corporate Data Warehouse (CDW).Patients who had missing variables were excluded from the final analysis.Missing variables excluded 7% of the original cohort.We did not impute race if that value was missing.

Using categories created from clinical evaluation of International Statistical Classification of
Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and classified by Healthcare Cost and Utilization Project (HCUP) procedure class flags, we included surgical procedures that were defined as major therapeutic or diagnostic procedures performed in the operating room for our analysis. 9Further designation of surgical procedures as high risk or non-high risk was based on prior work and ICD-10-CM codes. 6,10Figure 1 illustrates the cohort creation.

Outcomes
Our primary outcome was preoperative LST documentation within 30 days prior to surgery. 11We searched the CDW for a health factor metric named ethics-life-sustaining treatment, which indicated that an LST progress note had been activated.LST documentation was defined by completion and documentation of at least 4 mandatory elements: GOC about values and overall treatment purpose, resuscitation preferences, decision-making capacity or designation of a surrogate, and consent. 12rtial completion or no completion of these elements was considered incomplete LST documentation. 12Other LST components could include preferences regarding artificial nutrition and hydration.

Patient-and System-Level Characteristics
Our study was informed by the conceptual framework of access to health care and the health equity implementation framework. 7,13Race as a social construct is a widely accepted concept in multiple fields, including anthropology and sociology.The VHA collects patient information about race as a singular reported entity (American Indian, Asian, Black, Hispanic Black, Hispanic White, White, and unknown), reported either by self or by proxy.Importantly, veterans who identify as multiracial or multiethnic may not be reflected accurately in the CDW.We categorized race into 3 groups: Black or African American, White, and other (including American Indian or Alaskan Native, Asian, Native Hawaiian, or Other Pacific Islander).We defined ethnicity as Hispanic vs non-Hispanic individuals.
We also examined the association between LST completion and several other patient characteristics, including age, sex (male or female), marital status (married; divorced, widowed, or separated; and single or never married), housing instability, rurality of patient residence (rural vs urban), Care Assessment Need score within 1 year prior to day of surgery, Charlson Comorbidity Index (CCI) within 1 year prior to day of surgery, diagnoses of serious medical comorbidities (end stage kidney disease, cancer, cardiopulmonary arrest, dementia, frailty), history of mental health

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Disparities in Preoperative Goals of Care Documentation in Veterans comorbidity (major depression, posttraumatic stress disorder, psychotic disorders, bipolar disorder), and substance use disorder (the use of 1 or more of the following substances: alcohol, methamphetamine, cocaine, opiates, and sedative or anxiolytic) based on ICD-10-CM codes within the year prior to surgery. 6,12 investigate the potential moderating effect of rurality with the association of patient race or ethnicity and preoperative LST completion, we included an interaction term between these variables in our prespecified analysis. 12Surgical specialty types (cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, urology, vascular surgery, and other), surgical risk level (high risk or nonhigh risk), VA facility complexity, which is a reflection of patient volumes and resources for clinical, research, and teaching on site, and procedure year were used to account for temporal trends in the adjusted analysis. 11,14Table 1 indicates the definitions of VA facility levels.

Statistical Analysis
We summarized patient-level and system-level characteristics descriptively based on preoperative LST completion status.We calculated standardized mean differences (SMDs) to assess the magnitude of differences between the groups.We defined an SMD value of 0.2 as the threshold for determining meaningful differences between the groups. 15SMDs were calculated using the R package tableone version 0.13.2 (R Project for Statistical Computing). 16Our approach treated a multinomial variable as multiple nonredundant dichotomous variables and used the Mahalanobis distance, a measure between a sample point and a distribution, to calculate SMDs. 17Categorical variables were summarized as percentages, with the frequency and percentage of each category reported.Continuous variables were reported as mean (SD).
We used logistic regression to model the association between LST completion and patient characteristics, while adjusting for the complexity level of the VA facility where the surgery took place to estimate the odds ratios (ORs) and 95% CIs for each variable in the model.We included a patient's VA facility type as a fixed effect to account for clustering.To account for potential correlations within clusters of patients, we used a sandwich estimator to obtain robust standard errors and calculate 95% CIs. 18To account for potential temporal confounding, including the onset of the COVID-19 pandemic, we adjusted for procedure year in the statistical model.To assess the potential collinearity of the variables, we examined the Pearson correlation coefficients among independent variables.We used the variance inflation factor (VIF) to assess multicollinearity among explanatory variables and found that all VIF values were less than 5, indicating no issues with multicollinearity.We performed a sensitivity analysis on the logistic regression results by repeating the main analyses on an expanded cohort with completed LST documentation within 90 days before surgery.
All statistical analyses were performed using R version 4.0.5 (R Project for Statistical Computing) between October 2022 and February 2023.All P values were calculated based on 2-sided tests, and statistical significance was determined at the threshold of P < .05.With each passing year, patients undergoing surgical procedures had greater likelihoods of completing LST before surgery.Given the potential impact of the COVID-19 pandemic on LST completion rates, we examined the number of completed mechanical ventilation questions in the LST note over time.However, no significant association was found.

Discussion
We assessed disparities in preoperative GOC documentation for patients undergoing surgical procedures within the VHA system.We identified important risks for poor GOC documentation, before surgery.While there were greater odds of clinicians completing preoperative LST documentation for patients from racially or ethnically minoritized communities at lower-complexity VA facilities, patients undergoing surgical procedures from racially or ethnically minoritized communities, patients with a history of comorbid mental health disorders, and those who live in rural areas were significantly less likely to complete LST documentation.
Our study provides several opportunities for health care clinicians to engage with individuals from racially and ethnically minoritized communities in GOC discussions and improve preoperative goals documentation.Preoperative LST documentation rates were significantly lower for Black patients, Hispanic patients, and patients identifying as other (ie, American Indian or Alaskan Native, Asian, Native Hawaiian, or Other Pacific Islander) than for White patients.1][22] Rurality of residence also suggests cultural differences on an individual basis.Previous studies 6,23 have shown differences in LST documentation rates between urban and rural residents.However, in our study, rurality did not compound racial disparities in preoperative LST documentation.Elderly patients aged 65 years and older also tended to complete preoperative LST documentation, in line with a prior VA-based study 23 that found that patients who were older and seriously ill were more likely to have GOC documentation.Yet, patients who are not elderly can also have serious illnesses and derive benefit from GOC planning. 24,25tients undergoing surgical procedures with comorbid psychiatric disability are also at risk for not engaging in preoperative GOC discussions.One in 5 US adults live with a mental health condition, and about 1 in 20 live with serious psychiatric disability. 26A cross-sectional study of psychiatric inpatients determined that 60% of the patients exhibited incapacity to make medical decisions b One or more of the following: alcohol, methamphetamine, cocaine, opiate, sedative or anxiolytic.
c One or more of the following: major depression, posttraumatic stress disorder, psychotic disorders, bipolar disorder.
about their care, underscoring the difficulties patients with comorbid mental health disabilities may face before a stressful and significant event like surgery. 27Patients with serious mental disabilities express interest in advance care planning, yet few have discussed their preferences with clinicians. 28r study's novel finding that a history of mental health disabilities was associated with lower rates of LST documentation highlights potential harmful biases clinicians may hold about these patients.One study 29 found that participants described feelings that clinicians do not treat people with mental health disabilities in a holistic manner; poor patient-clinician communication could extend to GOC discussions.For patients with serious mental disabilities, identifying surrogates for decision-making in cases where patient capacity is compromised is also important as social, legal, and ethical challenges may arise with conservators, illustrated by the lawsuit Conservatorship of Wendland. 30The patient was conscious but functionally impaired from a devastating accident; without an advance directive designating a durable power of attorney, his wife was his conservator, who was privy to knowledge that he did not want to live in a persistently vegetative state.However,

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Disparities in Preoperative Goals of Care Documentation in Veterans

Figure 2 .
Figure 2. Odds Ratios (ORs) of Select Factors on Preoperative Life-Sustaining Treatment Documentation for Veterans

Table 1 .
Veterans Affairs Facility Complexity Level Definitions aResultsOf the 229 737 veterans (209 123 [91%] male; 20 614 [9.0%] female; mean [SD] age, 65.5[11.9]years)at130VA facilities included in this study, 13 408 (5.8%) completed an LST note within 30 days prior to surgery (Table2).While SMD values varied, there were differences in patients who did and did not complete a documented preoperative LST.In unadjusted analyses, the patients who did not complete LST preoperatively compared with those who completed preoperative LST documentation 19Figure2shows the estimates from the covariate-adjusted regression model.The odds of completing preoperative LST were lower for Black veterans (OR, 0.79; 95% CI, 0.77-0.80;P < .001),other veterans (OR, 0.78; 95% CI, 0.74-0.81;P < .001),compared with White individuals (eTable in Supplement 1).Rurality did not modify the association between patient's race and preoperative LST completion.Hispanic patients were less likely to complete LST than non-Hispanic patients (OR, 0.78; 95% CI, 0.76-0.81;P < .001)(eTable in Supplement 1).Patients with mental health disorder history also had lower likelihood (OR, 0.93; 95% CI, 0.92-0.94;P = .001) of completing an LST note before surgery than those without such history.Male patients (OR, 1.18; 95% CI, 1.14-1.22;P < .001),those with history of substance use (OR, 1.08; 95% CI, 1.06-1.10;P = .004),and those who resided in urban areas (OR, 1.09; 95% CI, 1.08-1.11;P < .001)were more likely to complete preoperative LST notes compared with their counterparts.Patients who underwent surgery at level 1A facilities, which have the highest complexity, had the least likelihood of completing preoperative LST notes.After we performed a sensitivity analysis on the logistic regression results with a wider time window for preoperative LST completion, there was minimal change observed in the findings.Odds ratios associated with factors with increased likelihood of preoperative LST documentation exhibited a greater magnitude.The overall conclusion and interpretation drawn from the study remained unaffected.

Table 2 .
Disparities in Preoperative Goals of Care Documentation in Veterans Cohort Baseline Characteristics novel associations with patients' history of mental health disorder.Despite increasing rates of preoperative LST documentation over time, even during the COVID-19 pandemic, a low proportion of patients undergoing surgical procedures overall, particularly individuals from racially and ethnically minoritized communities and patients from rural regions, completed LST documentation JAMA Network Open | Equity, Diversity, and Inclusion

Table 2 .
Cohort Baseline Characteristics (continued) a Other race includes American Indian or Alaskan Native, Asian, Native Hawaiian, or Other Pacific Islander.
CAN indicates care assessment need score; CCI, Charlson Comorbidity Index; ESKD, end-stage kidney disease.