Variation in Do-Not-Resuscitate Orders for Patients With Ischemic Stroke

Abstract

Background and purpose Decisions on life-sustaining treatments and the use of do-not-resuscitate (DNR) orders can affect early mortality after stroke. We investigated the variation in early DNR utilization after stroke among hospitals in California, and the impact of this variation on mortality-based hospital classifications. Methods Using the California State Inpatient Database from 2005–2011, ischemic stroke admissions for patients age ≥50 were identified. Cases were categorized by the presence/absence of DNR orders within the first 24 hours of admission. Multilevel logistic regression models with a random hospital intercept were used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors and demographics. Hospital mortality rank order was assigned based on this model and compared to the results of a second model that included DNR status. Results From 355 hospitals, 252,368 cases were identified, including 33,672 (13.3%) with early DNR. Hospital-level adjusted utilization of DNR varied widely (quintile 1, 2.2% vs. quintile 5, 23.2%). Hospitals with higher early DNR utilization had higher inpatient mortality, as inpatient mortality more than doubled from quintile 1 (4.2%) to quintile 5 (8.7%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum, including among high mortality hospitals. Conclusions There is wide variation in the hospital-level proportion of ischemic stroke patients with early DNR orders; this variation affects hospital mortality estimates. Unless the circumstances of early DNR orders are better understood, mortality-based hospital comparisons may not reliably identify hospitals providing a lower quality of care.

Alignment of Do-Not-Resuscitate Status With Patients’ Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest

“…Several studies have reported rates of DNR orders in patients hospitalized with other disease conditions, ranging from 9% in acute myocardial infarction, 22 13-22% in acute stroke, 23, 24 22% in community-acquired pneumonia, 25 to 38-47% in initial survivors of out-of-hospital cardiac arrest. 26, 27 While these prior studies reported overall rates of DNR, they did not assess whether code status decision-making was aligned with a patient's prognosis.…”

Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines–Stroke Hospitals

“…Wide hospital variation in the use of do-not-resuscitate orders for stroke patients has been previously demonstrated and are strongly linked to hospital stroke mortality estimates. 41,42 Third, while we accounted for regional differences in race, other socioeconomic factors may account for some of the unexplained variation in outcomes. This may be particularly important for readmissions, which are highly influenced by socioeconomic factors.…”

Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest

“…5,26–28 Moreover, patients made DNR were less likely to receive appropriate medical care unrelated to emergent resuscitation, such as intensive care unit transfer, intravenous antihypertensive therapy, and deep venous thrombosis prophylaxis for intracranial hemorrhage, 3 cardiac catheterization and internal cardiac defibrillator placement for out-of-hospital cardiac arrest, 25 and left ventricular function assessment, renin-angiotensin system blockade, and diet/lifestyle counseling for heart failure. 4 Finally, four studies have previously addressed variation across hospitals in regard to early DNR status adoption and associated survival outcomes, albeit in different cohorts of patients with intracranial hemorrhage, 22 ischemic stroke, 24 traumatic brain injury, 29 or out-of-hospital cardiac arrest 25 (a very different population than that of patients with in-hospital arrest events 30,31 ). As with our study results, all four prior studies also reported wide variation in hospital rates of DNR status adoption, from 0 to 80%, and worse survival associated with higher hospital rates of DNR.…”