Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans.

IF 15.7 1区 医学 Q1 SURGERY JAMA surgery Pub Date : 2024-10-01 DOI:10.1001/jamasurg.2024.2489
Michael A Jacobs, Yubo Gao, Susanne Schmidt, Paula K Shireman, Michael Mader, Carly A Duncan, Leslie R M Hausmann, Karyn B Stitzenberg, Lillian S Kao, Mary Vaughan Sarrazin, Daniel E Hall
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Abstract

Importance: Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement.

Objective: To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR).

Design, setting, and participants: This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024.

Exposure: Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days).

Main outcomes and measures: DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures).

Results: The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation.

Conclusions and relevance: Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.

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老年退伍军人健康的社会决定因素和结果排名的手术可取性。
重要性:评估健康的社会决定因素(SDOH)如何影响退伍军人的治疗效果至关重要,尤其是在提高质量方面:使用结果可取性排名(DOOR)来衡量 SDOH、护理分散性和手术结果之间的关联:这是一项针对美国退伍军人的队列研究,使用的数据来自退伍军人事务局(VA)外科质量改进计划(VASQIP;2013-2019 年),仅限于年龄在 65 岁或以上、住院时间在 2 到 30 天之间的患者,并与包括医疗保险在内的多种数据源进行了合并。种族和民族数据取自 VASQIP、医疗保险和医疗补助受益人汇总文件、退伍军人健康管理局企业数据仓库以及美国退伍军人资格趋势和统计文件。数据分析时间为 2023 年 9 月至 2024 年 2 月:主要结果和测量指标:DOOR是一个以患者为中心的综合排名,包含26项结果,从无并发症(1,最佳)到90天死亡率或濒死并发症(6,最差)。采用一系列比例几率回归评估SDOH和护理分散的影响,并对临床风险因素进行调整,包括就诊急症(术前出现急性重症和紧急或急诊外科手术):队列中有 93 644 名患者(平均 [SD] 年龄 72.3 [6.2] 岁;91 443 [97.6%] 男性;74 624 [79.7%] 白人)。黑人退伍军人(调整后的几率比 [aOR],1.06;95% CI,1.02-1.10;P = .048)与白人退伍军人以及护理分散程度较高的退伍军人(退伍军人护理天数相对于所有护理天数每增加 20%:aOR,1.01;95% CI,1.01-1.02;P 结论及相关性:黑人退伍军人和接受非退伍军人护理比例较高的退伍军人的手术效果较差。退伍军人事务部的计划应将资源用于减少黑人退伍军人的急诊,鼓励退伍军人尽可能在退伍军人事务部内接受治疗,并更好地协调退伍军人的治疗和记录。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
JAMA surgery
JAMA surgery SURGERY-
CiteScore
20.80
自引率
3.60%
发文量
400
期刊介绍: JAMA Surgery, an international peer-reviewed journal established in 1920, is the official publication of the Association of VA Surgeons, the Pacific Coast Surgical Association, and the Surgical Outcomes Club.It is a proud member of the JAMA Network, a consortium of peer-reviewed general medical and specialty publications.
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