Variation in do-not-resuscitate orders for patients with ischemic stroke: implications for national hospital comparisons

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 use after stroke among hospitals in California and the effect of this variation on mortality-based hospital classifications.

Methods: Using the California State Inpatient Database from 2005 to 2011, ischemic stroke admissions for patients aged≥50 years were identified. Cases were categorized by the presence or the 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 with 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 use of DNR varied widely (quintile 1, 2.2% versus quintile 5, 23.2%). Hospitals with higher early DNR use had higher inpatient mortality because 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.

Keywords: mortality; outcome assessment (health care); resuscitation orders; stroke.

Figure 1

Variation in use of DNR orders and associated inpatient mortality. Darker bars represent the unadjusted proportion of patients with a DNR order across hospital DNR quintiles; lighter bars represent the proportion after adjusting for demographics, vascular risk factors, comorbidities, prior vascular events and transfer status relative to the leftmost y-axis. The dashed line represents mean unadjusted inpatient mortality across quintiles relative to the rightmost y-axis.

Figure 2

Comparison of hospital ranking with and without adjustment for DNR status. Each dot represents an individual hospital. The y-axis represents the hospital’s ranking assigned from the non-DNR model and the x-axis represents the hospital’s ranking on the model including DNR.