ImportanceEvaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement.ObjectiveTo measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR).Design, Setting, And ParticipantsThis 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.ExposureLiving 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 MeasuresDOOR 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).ResultsThe 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 RelevanceVeterans 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.

中文翻译：

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老年退伍军人健康的社会决定因素和手术可取性结果排名


重要性评估健康的社会决定因素 （SDOH） 如何影响退伍军人的结果至关重要，尤其是对于质量改进。目的使用结果合意性排名 （DOOR） 测量 SDOH、护理碎片化和手术结果之间的关联。设计、设置和参与者这是一项针对美国退伍军人的队列研究，使用来自退伍军人事务部 （VA） 手术质量改进计划 （VASQIP;2013-2019） 的数据，该计划仅限于 65 岁或以上且住院时间在 2 至 30 天之间的患者，并与多个数据源合并，包括 Medicare。种族和民族数据从 VASQIP、Medicare 和 Medicaid 受益人摘要文件、退伍军人健康管理局企业数据仓库和美国退伍军人资格趋势和统计文件中检索。数据在 2023 年 9 月至 2024 年 2 月期间进行了分析。暴露生活在高度贫困的社区（面积剥夺指数 >85）、种族和民族用作社会结构、农村和护理碎片化（非 VA 护理天数的百分比）。主要结果和措施DOOR 是一个以患者为中心的综合排名，包含 26 个结果，范围从无并发症（1 个，最好）到 90 天死亡率或濒死并发症（6 个，最差）。使用一系列比例比值回归来评估 SDOH 和护理碎片化的影响，根据临床危险因素进行调整，包括表现敏锐度 （表现为术前急性严重疾病和紧急或紧急外科手术）。结果该队列有 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）。被认定为黑人的退伍军人（调整后比值比 [aOR]，1.06;95% CI，1.02-1.10;P = .048） 与护理碎片化程度较高的白人和退伍军人（相对于所有护理天数，VA 护理天数每增加 20%：aOR，1.01;95% CI，1.01-1.02;P < .001） 与较差（较高）的 DOOR 评分相关，直到调整表现敏锐度。与居住在城市地区相比，生活在农村地理区域的 DOOR 评分更高 （aOR， 0.93;95% CI， 0.91-0.96;P < .001），农村与较低的表现敏锐度相关（术前急性严重情况：aOR，0.88;95% CI，0.81-0.95;P = .001）。被认定为黑人、生活在贫困社区且护理碎片化程度增加的退伍军人的表现敏锐度更高。结论和相关性认同为黑人的退伍军人和非 VA 护理比例较高的退伍军人的手术结果更差。VA 计划应将资源用于降低黑人退伍军人的表现敏锐度，激励退伍军人在可能的情况下在 VA 内接受护理，并更好地协调护理来源之间的退伍军人治疗和记录。