1
|
Yeh HL, Hsieh FI, Lien LM, Kuo WH, Jeng JS, Sun Y, Wei CY, Yeh PY, Yip HT, Lin CL, Huang N, Hsu KC. Patient and hospital characteristics associated with do-not-resuscitate/do-not-intubate orders: a cross-sectional study based on the Taiwan stroke registry. BMC Palliat Care 2023; 22:138. [PMID: 37715158 PMCID: PMC10503153 DOI: 10.1186/s12904-023-01257-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Previous studies of do-not-resuscitate (DNR) or do-not-intubate (DNI) orders in stroke patients have primarily been conducted in North America or Europe. However, characteristics associated with DNR/DNI orders in stroke patients in Asia have not been reported. METHODS Based on the Taiwan Stroke Registry, this nationwide cross-sectional study enrolled hospitalized stroke patients from 64 hospitals between 2006 and 2020. We identified characteristics associated with DNR/DNI orders using a two-level random effects model. RESULTS Among the 114,825 patients, 5531 (4.82%) had DNR/DNI orders. Patients with acute ischemic stroke (AIS) had the highest likelihood of having DNR/DNI orders (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.61-1.93), followed by patients with intracerebral hemorrhage (ICH), and patients with subarachnoid hemorrhage (SAH) had the lowest likelihood (aOR 0.53, 95% CI 0.43-0.66). From 2006 to 2020, DNR/DNI orders increased in all three types of stroke. In patients with AIS, women were significantly more likely to have DNR/DNI orders (aOR 1.23, 95% CI 1.15-1.32), while patients who received intravenous alteplase had a lower likelihood (aOR 0.74, 95% CI 0.65-0.84). Patients with AIS who were cared for by religious hospitals (aOR 0.55, 95% CI 0.35-0.87) and patients with SAH who were cared for by medical centers (aOR 0.40, 95% CI 0.17-0.96) were significantly less likely to have DNR/DNI orders. CONCLUSIONS In Taiwan, DNR/DNI orders increased in stroke patients between 2006 and 2020. Hospital characteristics were found to play a significant role in the use of DNR/DNI orders.
Collapse
Affiliation(s)
- Hsu-Ling Yeh
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Fang-I Hsieh
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Wen-Hua Kuo
- Institute of Science, Technology, and Society, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center, Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Cheng-Yu Wei
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei, Taiwan
| | - Po-Yen Yeh
- Department of Neurology, St. Martin de Porres Hospital, Chiayi City, Taiwan
| | - Hei-Tung Yip
- Management office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No. 155, Section 2, Li-Nong Street, Taipei 112, Taipei, Taiwan.
| | - Kai-Cheng Hsu
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
2
|
DeHoff G, Lau W. Medical management of cerebral edema in large hemispheric infarcts. Front Neurol 2022; 13:857640. [DOI: 10.3389/fneur.2022.857640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
Acute ischemic stroke confers a high burden of morbidity and mortality globally. Occlusion of large vessels of the anterior circulation, namely the intracranial carotid artery and middle cerebral artery, can result in large hemispheric stroke in ~8% of these patients. Edema from stroke can result in a cascade effect leading to local compression of capillary perfusion, increased stroke burden, elevated intracranial pressure, herniation and death. Mortality from large hemispheric stroke is generally high and surgical intervention may reduce mortality and improve good outcomes in select patients. For those patients who are not eligible candidates for surgical decompression either due timing, medical co-morbidities, or patient and family preferences, the mainstay of medical management for cerebral edema is hyperosmolar therapy. Other neuroprotectants for cerebral edema such as glibenclamide are under investigation. This review will discuss current guidelines and evidence for medical management of cerebral edema in large hemispheric stroke as well as discuss important neuromonitoring and critical care management targeted at reducing morbidity and mortality for these patients.
Collapse
|
3
|
Shah S, Makhnevich A, Cohen J, Zhang M, Marziliano A, Qiu M, Liu Y, Diefenbach MA, Carney M, Burns E, Sinvani L. Early DNR in Older Adults Hospitalized with SARS-CoV-2 Infection During Initial Pandemic Surge. Am J Hosp Palliat Care 2022; 39:1491-1498. [PMID: 35510776 DOI: 10.1177/10499091221084653] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8, P < .001), women (51.2% vs 43.6%, P = .012), with higher comorbidity index (3.88 vs 3.36, P < .001), facility-based (49.1% vs 19.1%, P < .001), with dementia (13.3% vs 4.6%, P < .001), and severely ill on presentation (57.9% vs 32.3%, P < .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10-4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40-.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21-.67), and shorter length of stay (LOS, 4.8 vs 10.3 days, P < .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85-1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40-.75), IMV (OR: 0.53, 95% CI: 0.29-.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30-.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.
Collapse
Affiliation(s)
- Shalin Shah
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Alex Makhnevich
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Jessica Cohen
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Meng Zhang
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Allison Marziliano
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Michael Qiu
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Yan Liu
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Michael A Diefenbach
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| | - Maria Carney
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Division of Geriatrics and Palliative Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA
| | - Edith Burns
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA.,Division of Geriatrics and Palliative Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA
| | - Liron Sinvani
- Division of Hospital Medicine, Department of Medicine, 5799Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, 583266Northwell Health, Manhasset, NY, USA
| |
Collapse
|
4
|
Goostrey K, Muehlschlegel S. Prognostication and shared decision making in neurocritical care. BMJ 2022; 377:e060154. [PMID: 35696329 DOI: 10.1136/bmj-2021-060154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient's behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.
Collapse
Affiliation(s)
- Kelsey Goostrey
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Susanne Muehlschlegel
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of anesthesiology/critical care, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
5
|
De Georgia M. The intersection of prognostication and code status in patients with severe brain injury. J Crit Care 2022; 69:153997. [PMID: 35114602 DOI: 10.1016/j.jcrc.2022.153997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.
Collapse
Affiliation(s)
- Michael De Georgia
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America.
| |
Collapse
|
6
|
Gao L, Zhao CW, Hwang DY. End-of-Life Care Decision-Making in Stroke. Front Neurol 2021; 12:702833. [PMID: 34650502 PMCID: PMC8505717 DOI: 10.3389/fneur.2021.702833] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/31/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.
Collapse
Affiliation(s)
- Lucy Gao
- Yale School of Medicine, New Haven, CT, United States
| | | | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
7
|
Epidemiologic Trends of Adoption of Do-Not-Resuscitate Status After Pediatric In-Hospital Cardiac Arrest. Pediatr Crit Care Med 2019; 20:e432-e440. [PMID: 31246741 DOI: 10.1097/pcc.0000000000002048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the prevalence of do-not-resuscitate status, assess the epidemiologic trends of do-not-resuscitate status, and assess the factors associated with do-not-resuscitate status in children after in-hospital cardiac arrest using large, multi-institutional data. DESIGN Generalized estimating equations logistic regression model was used to evaluate the trends of do-not-resuscitate status and evaluate the factors associated with do-not-resuscitate status after cardiac arrest. SETTING American Heart Association's Get With the Guidelines-Resuscitation Registry. PATIENTS Children (< 18 yr old) with an index in-hospital cardiac arrest and greater than or equal to 1 minute of documented chest compressions were included (2006-2015). Patients with no return of spontaneous circulation after cardiac arrest were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 8,062 patients qualified for inclusion. Of these, 1,160 patients (14.4%) adopted do-not-resuscitate status after cardiac arrest. We found low rates of survival to hospital discharge among children with do-not-resuscitate status (do-not-resuscitate vs no do-not-resuscitate: 6.0% vs 69.7%). Our study found that rates of do-not-resuscitate status after cardiac arrest are highest in children with Hispanic ethnicity (16.4%), white race (15.0%), and treatment at institutions with larger PICUs (> 50 PICU beds: 17.8%) and at institutions located in North Central (17.6%) and South Atlantic/Puerto Rico (17.1%) regions of the United States. Do-not-resuscitate status was more common among patients with more preexisting conditions, longer duration of cardiac arrest, greater than 1 cardiac arrest, and among patients requiring extracorporeal cardiopulmonary resuscitation. We also found that trends of do-not-resuscitate status after cardiac arrest in children are decreasing in recent years (2013-2015: 13.8%), compared with previous years (2006-2009: 16.0%). CONCLUSIONS Patient-, hospital-, and regional-level factors are associated with do-not-resuscitate status after pediatric cardiac arrest. As cardiac arrest might be a signal of terminal chronic illness, a timely discussion of do-not-resuscitate status after cardiac arrest might help families prioritize quality of end-of-life care.
Collapse
|
8
|
Kerever S, Crozier S, Mino JC, Gisquet E, Resche-Rigon M. Influence of nurse's involvement on practices during end-of-life decisions within stroke units. Clin Neurol Neurosurg 2019; 184:105410. [PMID: 31310921 DOI: 10.1016/j.clineuro.2019.105410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Decision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions. PATIENTS AND METHODS This secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision. RESULTS Among the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03). CONCLUSION The involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.
Collapse
Affiliation(s)
- Sébastien Kerever
- Departments of Anesthesiology and Critical Care, Lariboisière University Hospital, AP-HP, Paris, France; ECSTRA Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre UMR 1153, Inserm, Paris, France; University of Paris VII Denis Diderot, Paris, France.
| | - Sophie Crozier
- Stroke unit Department, Pitié-Salpêtrière University Hospital, APHP, Paris, France.
| | | | - Elsa Gisquet
- Centre de Sociologie des Organisations/ FNSP, Paris, France.
| | - Matthieu Resche-Rigon
- University of Paris VII Denis Diderot, Paris, France; Biostatistics and Medical Information Departments, Saint Louis University Hospital, AP-HP, Paris, France; ECSTRA Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre UMR 1153, Inserm, Paris, France.
| |
Collapse
|
9
|
Faigle R, Gottesman RF. Variability in Palliative Care Use after Intracerebral Hemorrhage at US Hospitals: A Multilevel Analysis. Neuroepidemiology 2019; 53:84-92. [PMID: 31238305 DOI: 10.1159/000500276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/09/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Palliative care (PC) is an essential component of comprehensive care of patients with intracerebral hemorrhage (ICH). In the present study, we sought to characterize the variability of PC use after ICH among US hospitals. METHODS ICH admissions from hospitals with at least 12 annual ICH cases were identified in the Nationwide Inpatient Sample between 2008 and 2011. We used multilevel logistic regression modeling to estimate between-hospital variance in PC use. We calculated the intraclass correlation coefficient (ICC), proportional variance change, and median OR after accounting for individual-level and hospital-level covariates. RESULTS Among 26,791 ICH admissions, 12.5% received PC (95% CI 11.5-13.5). Among the 629 included hospitals, the median rate of PC use was 9.1 (interquartile range 1.5-19.3) per 100 ICH admissions, and 150 (23.9%) hospitals had no recorded PC use. The ICC of the random intercept (null) model was 0.274, suggesting that 27.4% of the overall variability in PC use was due to between-hospital variability. Adding hospital-level covariates to the model accounted for 25.8% of the between-hospital variance observed in the null model, with 74.2% of between-hospital variance remaining unexplained. The median OR of the fully adjusted model was 2.62 (95% CI 2.41-2.89), indicating that a patient moving from 1 hospital to another with a higher intrinsic propensity of PC use had a 2.63-fold median increase in the odds of receiving PC, independent of patient and hospital factors. CONCLUSIONS Substantial variation in PC use after ICH exists among US hospitals. A substantial proportion of this between-hospital variability remains unexplained even after accounting for patient and hospital characteristics.
Collapse
Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
10
|
Bailoor K, Shafie-Khorassani F, Lank RJ, Case E, Garcia NM, Lisabeth LD, Sánchez BN, Kim S, Morgenstern LB, Zahuranec DB. Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke. Stroke 2019; 50:1641-1647. [PMID: 31177986 DOI: 10.1161/strokeaha.118.024460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose- Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods- Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an interaction term added to allow separate hazard ratios for early (≤24 hours) and late (>24 hours) DNR. Stroke type-specific calendar trends were assessed with an interaction term between calendar year (linear) and stroke type. Results- Two thousand six hundred seventy-two cases were included (ICH, 14%). Mean age was 69, 50% were female, and race-ethnicity was Mexican American (58%), non-Hispanic white (37%), and African American (5%). Overall, 16% had a DNR order during the hospitalization. For ICH, DNR orders (early and late) were stable over the study period. However, early DNR orders became more common over time after ischemic stroke (hazard ratio for 2016 versus 2007: 1.89; 95% CI, 1.06-3.39), with no change over time for late DNR orders after ischemic stroke. Mexican Americans (hazard ratio, 0.65; 95% CI, 0.50-0.86) and African Americans (hazard ratio, 0.17; 95% CI, 0.04-0.71) were less likely than non-Hispanic whites to have early DNR orders, though there were no race-ethnic differences in late DNR orders. There was no change in race-ethnic difference in DNR orders over the time of the study (interaction P>0.60). Conclusions- Despite revised national guidelines cautioning against early DNR orders in ICH, presence of DNR orders after ICH was stable between 2007 and 2016, with only slight increases in early DNR orders after ischemic stroke. Mexican Americans and African Americans remain less likely than non-Hispanic whites to have early DNR orders after stroke.
Collapse
Affiliation(s)
- Kunal Bailoor
- From the Department of Internal Medicine (K.B.), Michigan Medicine, Ann Arbor
| | - Fatema Shafie-Khorassani
- Department of Biostatistics (F.S.-K., B.N.S., S.K.), University of Michigan School of Public Health, Ann Arbor
| | - Rebecca J Lank
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor
| | - Erin Case
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor.,Department of Epidemiology (E.C., L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor
| | - Nelda M Garcia
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor
| | - Lynda D Lisabeth
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor.,Department of Epidemiology (E.C., L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor
| | - Brisa N Sánchez
- Department of Biostatistics (F.S.-K., B.N.S., S.K.), University of Michigan School of Public Health, Ann Arbor
| | - Sehee Kim
- Department of Biostatistics (F.S.-K., B.N.S., S.K.), University of Michigan School of Public Health, Ann Arbor
| | - Lewis B Morgenstern
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor.,Department of Epidemiology (E.C., L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor
| | - Darin B Zahuranec
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor
| |
Collapse
|
11
|
Bruckel J, Nallamothu BK, Ling F, Howell EH, Lowenstein CJ, Thomas S, Bradley SM, Mehta A, Walkey AJ. Do-Not-Resuscitate Status and Risk-Standardized Mortality and Readmission Rates Following Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 12:e005196. [PMID: 30879325 PMCID: PMC6424127 DOI: 10.1161/circoutcomes.118.005196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Important administrative-based measures of hospital quality, including those used by Centers for Medicare and Medicaid Services, may not adequately account for patient illness and social factors that vary between hospitals and can strongly affect outcomes. Do-not-resuscitate (DNR) order on admission (within the first 24 hours) is one such factor that may reflect higher preadmission illness burden as well as patients' desire for less-intense therapeutic interventions and has been shown to vary widely between hospitals. We sought to evaluate how accounting for early DNR affected hospital quality measures for acute myocardial infarction. Methods AND RESULTS We identified all patients admitted with acute myocardial infarction using the California State Inpatient Database, which captures early DNR use within 24 hours of admission. We generated hospital risk-standardized mortality and readmissions using random-effects logistic regression, before and after including early DNR status, to examine changes in overall model fit and hospital outlier designations. We included 109 521 patients from 289 hospitals and found that 8.5% (9356) patients had early DNR. Early DNR use varied widely, with median (interquartile range) hospital rates of 7.9% (4.1%-14.0%). Including early DNR in models used to assess hospital quality resulted in improvement in the mortality model (C statistics from 0.754 [0.748-0.759] to 0.784 [0.779-0.789]) but not the readmissions model. Of the hospitals designated high outliers for mortality and readmissions by the Centers for Medicare/Medicaid Services model, and therefore destined for a financial penalty, 6/25 (24%) were reclassified as nonoutliers for mortality and 2/14 (14.3%) for readmissions after including DNR status. Agreement in outlier status between the models before and after inclusion of early DNR status was moderate for mortality (κ, 0.603 [0.482-0.724]; P<0.001) and high for readmissions (κ, 0.888 [0.800-0.977]; P<0.001). Conclusions Including early DNR status in risk-adjustment models significantly improved model fit and resulted in substantial reclassification of hospital performance rankings for mortality and moderate reclassification for readmissions. DNR status at hospital admission should be considered when reporting risk-standardized hospital mortality.
Collapse
Affiliation(s)
- Jeffrey Bruckel
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Brahmajee K. Nallamothu
- University of Michigan Health System, Division of Cardiovascular Medicine and Michigan Integrated Center for Health Analytics and Medical Prediction (M-CHAMP), Ann Arbor, MI; Ann Arbor VA Center for Clinical Management and Research, Ann Arbor, MI
| | - Frederick Ling
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Erik H. Howell
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Charles J. Lowenstein
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Sabu Thomas
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Anuj Mehta
- Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, CO; Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO National Jewish Health, Denver, CO
| | - Allan J. Walkey
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University Medical Center, Boston,MA
| |
Collapse
|
12
|
Thompson MP, Zhao X, Bekelis K, Gottlieb DJ, Fonarow GC, Schulte PJ, Xian Y, Lytle BL, Schwamm LH, Smith EE, Reeves MJ. Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines-Stroke Hospitals. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.003604. [PMID: 28798017 DOI: 10.1161/circoutcomes.117.003604] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND We explored regional variation in 30-day ischemic stroke mortality and readmission rates and the extent to which regional differences in patients, hospitals, healthcare resources, and a quality of care composite care measure explain the observed variation. METHODS AND RESULTS This ecological analysis aggregated patient and hospital characteristics from the Get With The Guidelines-Stroke registry (2007-2011), healthcare resource data from the Dartmouth Atlas of Health Care (2006), and Medicare fee-for-service data on 30-day mortality and readmissions (2007-2011) to the hospital referral region (HRR) level. We used linear regression to estimate adjusted HRR-level 30-day outcomes, to identify HRR-level characteristics associated with 30-day outcomes, and to describe which characteristics explained variation in 30-day outcomes. The mean adjusted HRR-level 30-day mortality and readmission rates were 10.3% (SD=1.1%) and 13.1% (SD=1.1%), respectively; a modest, negative correlation (r=-0.17; P=0.003) was found between one another. Demographics explained more variation in readmissions than mortality (25% versus 6%), but after accounting for demographics, comorbidities accounted for more variation in mortality compared with readmission rates (17% versus 7%). The combination of hospital characteristics and healthcare resources explained 11% and 16% of the variance in mortality and readmission rates, beyond patient characteristics. Most of the regional variation in mortality (65%) and readmission (50%) rates remained unexplained. CONCLUSIONS Thirty-day mortality and readmission rates vary substantially across HRRs and exhibit an inverse relationship. While regional variation in 30-day outcomes were explained by patient and hospital factors differently, much of the regional variation in both outcomes remains unexplained.
Collapse
Affiliation(s)
- Michael P Thompson
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.).
| | - Xin Zhao
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Kimon Bekelis
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Daniel J Gottlieb
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Gregg C Fonarow
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Phillip J Schulte
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Ying Xian
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Barbara L Lytle
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Lee H Schwamm
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Eric E Smith
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| | - Mathew J Reeves
- From the Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN (M.P.T.); Duke Clinical Research Institute, Durham, NC (X.Z., Y.X., B.L.L.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., D.J.G.); Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.); Department of Health Science Research, Mayo Clinic, Rochester, MN (P.J.S.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); and Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (M.J.R.)
| |
Collapse
|
13
|
Patel K, Sinvani L, Patel V, Kozikowski A, Smilios C, Akerman M, Kiszko K, Maiti S, Hajizadeh N, Wolf‐Klein G, Pekmezaris R. Do‐Not‐Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score–Matched Analysis. J Am Geriatr Soc 2018; 66:924-929. [DOI: 10.1111/jgs.15347] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Karishma Patel
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Liron Sinvani
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Vidhi Patel
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | - Andrzej Kozikowski
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | - Christopher Smilios
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | | | - Kinga Kiszko
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Sutapa Maiti
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Negin Hajizadeh
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| | - Gisele Wolf‐Klein
- Division of Hospital Medicine, Department of MedicineNorthwell HealthManhasset New York
- Division of Geriatric and Palliative Medicine, Department of MedicineNorthwell HealthManhasset New York
| | - Renee Pekmezaris
- Division of Health Services Research, Department of MedicineCenter for Health Innovations and Outcomes ResearchManhasset New York
| |
Collapse
|
14
|
Chen LM, Levine DA, Hayward R, Cox M, Schulte PJ, DeVore AD, Hernandez A, Heidenreich PA, Yancy C, Fonarow GC. Relationship between Hospital 30-Day Mortality Rates for Heart Failure and Patterns of Early Inpatient Comfort Care. J Hosp Med 2018; 13:170-176. [PMID: 29505624 DOI: 10.12788/jhm.2862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services rewards hospitals that have low 30-day riskstandardized mortality rates (RSMR) for heart failure (HF). OBJECTIVE To describe the use of early comfort care for patients with HF, and whether hospitals that more commonly initiate comfort care have higher 30-day mortality rates. DESIGN A retrospective, observational study. SETTING Acute care hospitals in the United States. PATIENTS A total of 93,920 fee-for-service Medicare beneficiaries admitted with HF from January 2008 to December 2014 to 272 hospitals participating in the Get With The Guidelines-Heart Failure registry. EXPOSURE Early comfort care (defined as comfort care within 48 hours of hospitalization) rate. MEASUREMENTS A 30-day RSMR. RESULTS Hospitals' early comfort care rates were low for patients admitted for HF, with no change over time (2.5% to 2.6%, from 2008 to 2014, P = .56). Rates varied widely (0% to 40%), with 14.3% of hospitals not initiating comfort care for any patients during the first 2 days of hospitalization. Risk-standardized early comfort care rates were not correlated with RSMR (median RSMR = 10.9%, 25th to 75th percentile = 10.1% to 12.0%; Spearman's rank correlation = 0.13; P = .66). CONCLUSIONS Hospital use of early comfort care for HF varies, has not increased over time, and on average, is not correlated with 30-day RSMR. This suggests that current efforts to lower mortality rates have not had unintended consequences for hospitals that institute early comfort care more commonly than their peers.
Collapse
Affiliation(s)
- Lena M Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Deborah A Levine
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Rodney Hayward
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Margueritte Cox
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Adrian Hernandez
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina, USA
| | | | - Clyde Yancy
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Gregg C Fonarow
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina, USA
- Ahmanson-University of California at Los Angeles Cardiomyopathy Center, Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
15
|
Wang V, Hsieh CC, Huang YL, Chen CP, Hsieh YT, Chao TH. Different utilization of intensive care services (ICSs) for patients dying of hemorrhagic and ischemic stroke, a hospital-based survey. Medicine (Baltimore) 2018; 97:e0017. [PMID: 29465539 PMCID: PMC5841996 DOI: 10.1097/md.0000000000010017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The intensive care service (ICS) saves lives and rescues the neurological function of stroke patients. We wondered the different utilization of ICS for patients with ischemic and hemorrhagic stroke, especially those who died within 30 days after stroke.Sixty-seven patients died during 2011 to 2015 due to acute stroke (42 due to intracranial hemorrhage [ICH]; 25 due to cerebral infarct [CI]). The durations of hospital stay (hospital staying days [HSDs]) and ICS staying days (ISDs) and codes of the do-not-resuscitate (DNR) were surveyed among these medical records. Statistics included chi-square and descriptive analyses.In this study, CI patients had a longer HSD (mean 14.3 days), as compared with ICH patients (mean 8.3 days); however, the ICH patients had a higher percentage of early entry within the first 24 hours of admission into ICS than CI group (95.1% vs 60.0%, P = .003). A higher rate of CI patients died in holidays or weekends than those with ICH (44.0% vs 21.4%, P = .051). DNR, requested mainly from direct descendants (children or grandchildren), was coded in all 25 CI patients (100.0%) and 38 ICH patients (90.5%). More cases with early DNR coded within 24 hours after admission occurred in ICH group (47%, 12% in CI patients, P = .003). None of the stroke patient had living wills. Withhold of endotracheal intubation (ETI) occurred among CI patients, more than for ICH patients (76.0% vs 18.4%, P < .005).In conclusion, CI patients longer HSD, ISD, higher mortality within holidays or weekends, and higher ETI withhold; but less percentage of ICS utilization expressed by a lower ISD/HSD ratio. This ICS utilization is a key issue of medical quality for stroke care.
Collapse
Affiliation(s)
- Vinchi Wang
- Department of Neurology, Cardinal Tien Hospital
- School of Medicine, College of Medicine, Fu-Jen Catholic University
- Medical Quality Management Center
| | | | | | - Chia-Ping Chen
- Information Technology Office, Yonghe Cardinal Tien Hospital, New Taipei City, Taiwan
| | | | - Tzu-Hao Chao
- Department of Neurology, Cardinal Tien Hospital
- School of Medicine, College of Medicine, Fu-Jen Catholic University
| |
Collapse
|
16
|
Callaghan BC, Burke JF, Kerber KA, Skolarus LE, Ney JP, Magliocco B, Esper GJ. The association of neurologists with headache health care utilization and costs. Neurology 2018; 90:e525-e533. [PMID: 29321226 DOI: 10.1212/wnl.0000000000004925] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/27/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association of a neurologist visit with headache health care utilization and costs. METHODS Utilizing a large privately insured health care claims database, we identified patients with an incident headache diagnosis (ICD-9 codes 339.xx, 784.0x, 306.81) with at least 5 years follow-up. Patients with a subsequent neurologist visit were matched to controls without a neurologist visit using propensity score matching, accounting for 54 potential confounders and regional variation in neurologist density. Co-primary outcomes were emergency department (ED) visits and hospitalizations for headache. Secondary outcomes were quality measures (abortive, prophylactic, and opioid prescriptions) and costs (total, headache-related, and non-headache-related). Generalized estimating equations assessed differences in longitudinal outcomes between cases and controls. RESULTS We identified 28,585 cases and 57,170 controls. ED visits did not differ between cases and controls (p = 0.05). Hospitalizations were more common in cases in year 0-1 (0.2%, 95% confidence interval [CI] 0.2%-0.3% vs 0.01%, 95% CI 0.01%-0.02%; p < 0.01), with minimal differences in subsequent years. Costs (including non-headache-related costs) and high-quality and low-quality medication utilization were higher in cases in the first year and decreased toward control costs in subsequent years with small differences persisting over 5 years. Opioid prescriptions increased over time in both cases and controls. CONCLUSION Compared with those without a neurologist, headache patients who visit neurologists had a transient increase in hospitalizations, but the same ED utilization. Confounding by severity is the most likely explanation given the non-headache-related cost trajectory. Claims-based risk adjustment will likely underestimate disease severity of headache patients seen by neurologists.
Collapse
Affiliation(s)
- Brian C Callaghan
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta.
| | - James F Burke
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Kevin A Kerber
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Lesli E Skolarus
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - John P Ney
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Brandon Magliocco
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Gregory J Esper
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| |
Collapse
|
17
|
Faigle R, Ziai WC, Urrutia VC, Cooper LA, Gottesman RF. Racial Differences in Palliative Care Use After Stroke in Majority-White, Minority-Serving, and Racially Integrated U.S. Hospitals. Crit Care Med 2017; 45:2046-2054. [PMID: 29040110 PMCID: PMC5693642 DOI: 10.1097/ccm.0000000000002762] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Racial/ethnic differences in palliative care resource use after stroke have been recognized, but it is unclear whether patient or hospital characteristics drive this disparity. We sought to determine whether palliative care use after intracerebral hemorrhage and ischemic stroke differs between hospitals serving varying proportions of minority patients. DESIGN Population-based cross-sectional study. SETTING Inpatient hospital admissions from the Nationwide Inpatient Sample between 2007 and 2011. PATIENTS A total of 46,735 intracerebral hemorrhage and 331,521 ischemic stroke cases. INTERVENTIONS Palliative care use. MEASUREMENTS AND MAIN RESULTS Intracerebral hemorrhage and ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic minority stroke patients (< 25% minorities ["white hospitals"], 25-50% minorities ["mixed hospitals"], or > 50% minorities ["minority hospitals"]). Logistic regression was used to evaluate the association between race/ethnicity and palliative care use within and between the different hospital strata. Stroke patients receiving care in minority hospitals had lower odds of palliative care compared with those treated in white hospitals, regardless of individual patient race/ethnicity (adjusted odds ratio, 0.65; 95% CI, 0.50-0.84 for intracerebral hemorrhage and odds ratio, 0.62; 95% CI, 0.50-0.77 for ischemic stroke). Ethnic minorities had a lower likelihood of receiving palliative care compared with whites in any hospital stratum, but the odds of palliative care for both white and minority intracerebral hemorrhage patients was lower in minority compared with white hospitals (odds ratio, 0.66; 95% CI, 0.50-0.87 for white and odds ratio, 0.64; 95% CI, 0.46-0.88 for minority patients). Similar results were observed in ischemic stroke. CONCLUSIONS The odds of receiving palliative care for both white and minority stroke patients is lower in minority compared with white hospitals, suggesting system-level factors as a major contributor to explain race disparities in palliative care use after stroke.
Collapse
Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Wendy C. Ziai
- Department of Neurology, Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Victor C. Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lisa A. Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Rebecca F. Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| |
Collapse
|
18
|
Fendler TJ, Spertus JA, Kennedy KF, Chan PS. Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest. Am Heart J 2017; 193:108-116. [PMID: 29129249 DOI: 10.1016/j.ahj.2017.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend deferring prognostication for 48 to 72 hours after resuscitation from inhospital cardiac arrest. It is unknown whether hospitals vary in making patients who survive an arrest Do-Not-Resuscitate (DNR) early after resuscitation and whether a hospital's rate of early DNR is associated with its rate of favorable neurological survival. METHODS Within Get With the Guidelines-Resuscitation, we identified 24,899 patients from 236 hospitals who achieved return of spontaneous circulation (ROSC) after inhospital cardiac arrest between 2006 and 2012. Hierarchical models were constructed to derive risk-adjusted hospital rates of DNR status adoption ≤12 hours after ROSC and risk-standardized rates of favorable neurological survival (without severe disability; Cerebral Performance Category ≤2). The association between hospitals' rates of early DNR and favorable neurological survival was evaluated using correlation statistics. RESULTS Of 236 hospitals, 61.7% were academic, 83% had ≥200 beds, and 94% were urban. Overall, 5577 (22.4%) patients were made DNR ≤12 hours after ROSC. Risk-adjusted hospital rates of early DNR varied widely (7.1%-40.5%, median: 22.7% [IQR: 19.3%-26.1%]; median OR of 1.48). Significant hospital variation existed in risk-standardized rates of favorable neurological survival (3.5%-44.8%, median: 25.3% [IQR: 20.2%-29.4%]; median OR 1.72). Hospitals' risk-adjusted rates of early DNR were inversely correlated with their risk-standardized rates of favorable neurological survival (r=-0.179, P=.006). CONCLUSIONS Despite current guideline recommendations, many patients with inhospital cardiac arrest are made DNR within 12 hours after ROSC, and hospitals vary widely in rates of early DNR. Higher hospital rates of early DNR were associated with worse meaningful survival outcomes.
Collapse
Affiliation(s)
| | | | | | | | -
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
| |
Collapse
|
19
|
Bruckel J, Mehta A, Bradley SM, Thomas S, Lowenstein CJ, Nallamothu BK, Walkey AJ. Variation in Do-Not-Resuscitate Orders and Implications for Heart Failure Risk-Adjusted Hospital Mortality Metrics. JACC. HEART FAILURE 2017; 5:743-752. [PMID: 28958349 PMCID: PMC7552359 DOI: 10.1016/j.jchf.2017.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/17/2017] [Accepted: 07/27/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study evaluated the effect of patient do-not-resuscitate (DNR) status on hospital risk-adjusted heart failure mortality metrics. BACKGROUND Do-not-resuscitate orders limit the use of life-sustaining therapies. Patients with DNR orders have increased in-hospital mortality, and DNR rates vary among hospitals. Variations in DNR rates could strongly confound risk-adjusted hospital mortality rates for heart failure. METHODS We identified a cohort of adults with primary diagnosis of heart failure by using the 2011 California State Inpatient Database, a claims database that captures "early DNR," within 24 h of admission. Hospital-level risk-standardized in-hospital mortality was determined using random effects logistic regression. We explored changes in outlier status in models with and without early DNR status. RESULTS Among 55,865 patients from 290 hospitals hospitalized with heart failure, 12.1% (11.8% to 12.4%) had an early DNR order. Hospitals with higher risk-standardized DNR rates had higher risk-standardized mortality (ρ = 0.241; 95% confidence interval [CI]: 0.129 to 0.346; p < 0.001). Including DNR in models used to benchmark hospital mortality improved model performance (c-statistic from 0.821 [95% CI: 0.812 to 0.830] to 0.845 [95% CI: 0.837 to 0.853]; increased model explanatory power by 17%). Including DNR resulted in reclassification of 9.3% of hospitals' outlier status. Agreement in hospital outlier designation between models with and without DNR was low to moderate (kappa coefficient: 0.492; 95% CI: 0.331 to 0.654). CONCLUSIONS Accounting for DNR status resulted in a change in estimated risk-standardized mortality rates and classification of hospitals as performance "outliers." Given public reporting of heart failure mortality measurements and their influence on reimbursement, accounting for the presence of early DNR orders in quality measures should be considered.
Collapse
Affiliation(s)
- Jeffrey Bruckel
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, New York.
| | - Anuj Mehta
- Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health System, Denver, Colorado
| | | | - Sabu Thomas
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, New York
| | - Charles J Lowenstein
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, New York
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan; Michigan Integrated Center for Health Analytics and Medical Prediction, Ann Arbor, Michigan; Ann Arbor Veterans Affairs Center for Clinical Management and Research, Ann Arbor, Michigan
| | - Allan J Walkey
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University Medical Center, Boston, Massachusetts
| |
Collapse
|
20
|
Prabhakaran S, Cox M, Lytle B, Schulte PJ, Xian Y, Zahuranec D, Smith EE, Reeves M, Fonarow GC, Schwamm LH. Early transition to comfort measures only in acute stroke patients: Analysis from the Get With The Guidelines-Stroke registry. Neurol Clin Pract 2017; 7:194-204. [PMID: 28680764 DOI: 10.1212/cpj.0000000000000358] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/10/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Death after acute stroke often occurs after forgoing life-sustaining interventions. We sought to determine the patient and hospital characteristics associated with an early decision to transition to comfort measures only (CMO) after ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in the Get With The Guidelines-Stroke registry. METHODS We identified patients with IS, ICH, or SAH between November 2009 and September 2013 who met study criteria. Early CMO was defined as the withdrawal of life-sustaining treatments and interventions by hospital day 0 or 1. Using multivariable logistic regression, we identified patient and hospital factors associated with an early (by hospital day 0 or 1) CMO order. RESULTS Among 963,525 patients from 1,675 hospitals, 54,794 (5.6%) had an early CMO order (IS: 3.0%; ICH: 19.4%; SAH: 13.1%). Early CMO use varied widely by hospital (range 0.6%-37.6% overall) and declined over time (from 6.1% in 2009 to 5.4% in 2013; p < 0.001). In multivariable analysis, older age, female sex, white race, Medicaid and self-pay/no insurance, arrival by ambulance, arrival off-hours, baseline nonambulatory status, and stroke type were independently associated with early CMO use (vs no early CMO). The correlation between hospital-level risk-adjusted mortality and the use of early CMO was stronger for SAH (r = 0.52) and ICH (r = 0.50) than AIS (r = 0.15) patients. CONCLUSIONS Early CMO was utilized in about 5% of stroke patients, being more common in ICH and SAH than IS. Early CMO use varies widely between hospitals and is influenced by patient and hospital characteristics.
Collapse
Affiliation(s)
- Shyam Prabhakaran
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Margueritte Cox
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Barbara Lytle
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Phillip J Schulte
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Ying Xian
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Darin Zahuranec
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Eric E Smith
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Mathew Reeves
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Gregg C Fonarow
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| | - Lee H Schwamm
- Feinberg School of Medicine (SP), Northwestern University, Chicago, IL; Duke Clinical Research Institute (MC, BL, PJS, YX), Durham, NC; University of Michigan (DZ), Ann Arbor; Hotchkiss Brain Institute (EES), University of Calgary, Canada; Michigan State University (MR), East Lansing; Ahmanson Cardiomyopathy Center (GCF), UCLA, Los Angeles, CA; Stroke Service (LHS), Massachusetts General Hospital, Boston; and Duke University Medical Center (YX), Durham, NC
| |
Collapse
|
21
|
Geurts M, de Kort FA, de Kort PL, van Tuijl JH, van Thiel GJ, Kappelle LJ, van der Worp HB. Treatment restrictions in patients with severe stroke are associated with an increased risk of death. Eur Stroke J 2017; 2:244-249. [PMID: 29900408 PMCID: PMC5992732 DOI: 10.1177/2396987317704546] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/15/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Treatment restrictions in the first 2 days after intracerebral haemorrhage
have been independently associated with an increased risk of early death. It
is unknown whether these restrictions also affect mortality if these are
installed several days after stroke onset. Patients and methods Sixty patients with severe functional dependence at day 4 after ischaemic
stroke or intracerebral haemorrhage were included in this prospective
two-centre cohort study. The presence of treatment restrictions was assessed
at the day of inclusion. Information about mortality, functional outcome
(modified Rankin scale) score and quality of life (visual analogue scale)
was recorded 6 months after stroke onset. Poor outcome was defined as
modified Rankin scale >3. Satisfactory quality of life was defined as
visual analogue scale ≥ 60. Results At 6 months, 30 patients had died, 19 survivors had a poor functional outcome
and 9 patients had a poor quality of life. Treatment restrictions were
independently associated with mortality at 6 months (adjusted relative risk,
1.30; 95% confidence interval, 1.06–1.59; p = 0.01), but not with functional
outcome. Discussion Our findings were observed in 60 selected patients with severe stroke. Conclusion The instalment of treatment restrictions by itself may increase the risk of
death after stroke, even if the first 4 days have passed. In future stroke
studies, this potential confounder should be taken into account. Quality of
life was satisfactory in the majority of the survivors, despite considerable
disability.
Collapse
Affiliation(s)
- Marjolein Geurts
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, The Netherlands
| | - Floor As de Kort
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, The Netherlands
| | - Paul Lm de Kort
- Department of Neurology, Elisabeth-Twee Steden Ziekenhuis, The Netherlands
| | - Julia H van Tuijl
- Department of Neurology, Elisabeth-Twee Steden Ziekenhuis, The Netherlands
| | | | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, The Netherlands
| |
Collapse
|
22
|
Man S, Cox M, Patel P, Smith EE, Reeves MJ, Saver JL, Bhatt DL, Xian Y, Schwamm LH, Fonarow GC. Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization. Stroke 2017; 48:412-419. [DOI: 10.1161/strokeaha.116.014426] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 10/31/2016] [Accepted: 11/17/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Primary stroke center (PSC) certification was established to identify hospitals providing evidence-based care for stroke patients. The numbers of PSCs certified by Joint Commission (JC), Healthcare Facilities Accreditation Program, Det Norske Veritas, and State-based agencies have significantly increased in the past decade. This study aimed to evaluate whether PSCs certified by different organizations have similar quality of care and in-hospital outcomes.
Methods—
The study population consisted of acute ischemic stroke patients who were admitted to PSCs participating in Get With The Guidelines-Stroke between January 1, 2010, and December 31, 2012. Measures of care quality and outcomes were compared among the 4 different PSC certifications.
Results—
A total of 477 297 acute ischemic stroke admissions were identified from 977 certified PSCs (73.8% JC, 3.7% Det Norske Veritas, 1.2% Healthcare Facilities Accreditation Program, and 21.3% State-based). Composite care quality was generally similar among the 4 groups of hospitals, although State-based PSCs underperformed JC PSCs in a few key measures, including intravenous tissue-type plasminogen activator use. The rates of tissue-type plasminogen activator use were higher in JC and Det Norske Veritas (9.0% and 9.8%) and lower in State and Healthcare Facilities Accreditation Program certified hospitals (7.1% and 5.9%) (
P
<0.0001). Door-to-needle times were significantly longer in Healthcare Facilities Accreditation Program hospitals. State PSCs had higher in-hospital risk-adjusted mortality (odds ratio 1.23, 95% confidence intervals 1.07–1.41) compared with JC PSCs.
Conclusions—
Among Get With The Guidelines-Stroke hospitals with PSC certification, acute ischemic stroke quality of care and outcomes may differ according to which organization provided certification. These findings may have important implications for further improving systems of care.
Collapse
Affiliation(s)
- Shumei Man
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Margueritte Cox
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Puja Patel
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Eric E. Smith
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Mathew J. Reeves
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Jeffrey L. Saver
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Deepak L. Bhatt
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Ying Xian
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Lee H. Schwamm
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| | - Gregg C. Fonarow
- From Department of Neurology, Miami Valley Hospital, Wright State University Boonshoft School of Medicine, Dayton, OH (S.M.); the Duke Clinical Research Center, Durham, NC (M.C., Y.X.); Department of Advocacy and Quality, American Heart Association, Dallas, TX (P.P.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Division of Neurology, University of
| |
Collapse
|
23
|
Walkey AJ, Weinberg J, Wiener RS, Cooke CR, Lindenauer PK. Hospital Variation in Utilization of Life-Sustaining Treatments among Patients with Do Not Resuscitate Orders. Health Serv Res 2017; 53:1644-1661. [PMID: 28097649 DOI: 10.1111/1475-6773.12651] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders. DATA SOURCES/SETTING United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database. STUDY DESIGN Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital "early" DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions. DATA COLLECTION/EXTRACTION METHODS California State Inpatient Database, year 2011. PRINCIPAL FINDINGS Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates. CONCLUSIONS Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders.
Collapse
Affiliation(s)
- Allan J Walkey
- Department of Medicine, The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Renda Soylemez Wiener
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA.,Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Peter K Lindenauer
- Division of General Internal Medicine, Center for Quality of Care Research, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
| |
Collapse
|
24
|
Sarkari NN, Perman SM, Ginde AA. Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis. J Crit Care 2016; 36:134-139. [PMID: 27546762 DOI: 10.1016/j.jcrc.2016.06.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/26/2016] [Accepted: 06/29/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Do-not-attempt-resuscitation (DNAR) orders are common in severe sepsis, but the impact on clinical care is not known. Our primary objective was to determine the impact of early DNAR orders on in-hospital mortality and performance of key interventional procedures among severe sepsis hospitalizations. Our secondary objective was to further investigate what patient characteristics within the sepsis DNAR population affected outcomes. METHODS Using the 2010-2011 California State Inpatient Dataset, we analyzed hospitalizations for adults admitted through the emergency department with severe sepsis. Our primary predictor was a DNAR order, and our outcomes were in-hospital mortality and performance of interventional procedures. RESULTS Visits with early DNAR orders accounted for 20.3% of severe sepsis hospitalizations. An early DNAR order was a strong, independent predictor of higher in-hospital mortality (odds ratio [OR], 4.03; 95% confidence interval, 3.88-4.19) and lower performance of critical procedures: central venous line (OR, 0.70), mechanical ventilation (OR, 0.80), hemodialysis (OR, 0.61), and major operative procedure (OR, 0.46). Among those with early DNAR orders, older age and rural location were the strongest predictors for a lack of interventional procedures. CONCLUSION Although DNAR orders are not synonymous with "do not treat," they may unintentionally limit aggressive treatment for severe sepsis patients, especially in older adults.
Collapse
Affiliation(s)
- Neza N Sarkari
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| |
Collapse
|
25
|
Zahuranec DB, Fagerlin A, Sánchez BN, Roney ME, Thompson BB, Fuhrel-Forbis A, Morgenstern LB. Variability in physician prognosis and recommendations after intracerebral hemorrhage. Neurology 2016; 86:1864-71. [PMID: 27164665 DOI: 10.1212/wnl.0000000000002676] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/14/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score. METHODS A written survey with 2 ICH scenarios was completed by practicing neurologists and neurosurgeons. Selected factors were randomly varied (patient older vs middle age, Glasgow Coma Scale [GCS] score 7T vs 11, and presence vs absence of a validated prognostic score). Outcomes included predicted 30-day mortality and recommendations for initial treatment intensity (6-point scale ranging from 1 = comfort only to 6 = full treatment). RESULTS A total of 742 physicians were included (mean age 52, 32% neurosurgeons, 17% female). Physician predictions of 30-day mortality varied widely (mean [range] for the 4 possible combinations of age and GCS were 23% [0%-80%], 35% [0%-100%], 48% [0%-100%], and 58% [5%-100%]). Treatment recommendations also varied widely, with responses encompassing the full range of response options for each case. No physician demographic or personality characteristics were associated with treatment recommendations. Providing a prognostic score changed treatment recommendations, and the effect differed across cases. When the prognostic score suggested 0% chance of functional independence (76-year-old with GCS 7T), the likelihood of treatment limitations was increased (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.12-2.33) compared to no prognostic score. Conversely, if the score suggested a 66% chance of independence (63-year-old with GCS 11), treatment limitations were less likely (OR 0.62, 95% CI 0.43-0.88). CONCLUSIONS Physicians vary substantially in ICH prognostic estimates and treatment recommendations. This variability could have a profound effect on life and death decision-making and treatment for ICH.
Collapse
Affiliation(s)
- Darin B Zahuranec
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
| | - Angela Fagerlin
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Brisa N Sánchez
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Meghan E Roney
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Bradford B Thompson
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Andrea Fuhrel-Forbis
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Lewis B Morgenstern
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| |
Collapse
|
26
|
Walkey AJ, Weinberg J, Wiener RS, Cooke CR, Lindenauer PK. Association of Do-Not-Resuscitate Orders and Hospital Mortality Rate Among Patients With Pneumonia. JAMA Intern Med 2016; 176:97-104. [PMID: 26658673 PMCID: PMC6684128 DOI: 10.1001/jamainternmed.2015.6324] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Hospital quality measures that do not account for patient do-not-resuscitate (DNR) status may penalize hospitals admitting a greater proportion of patients with limits on life-sustaining treatments. OBJECTIVE To evaluate the effect of analytic approaches accounting for DNR status on risk-adjusted hospital mortality rates and performance rankings. DESIGN, SETTING, AND PARTICIPANTS A retrospective, population-based cohort study was conducted among adults hospitalized with pneumonia in 303 California hospitals between January 1 and December 31, 2011. We used hierarchical logistic regression to determine associations between patient DNR status, hospital-level DNR rates, and mortality measures. Changes in hospital risk-adjusted mortality rates after accounting for patient DNR status and interhospital variation in the association between DNR status and mortality were examined. Data analysis was conducted from January 16 to September 16, 2015. EXPOSURES Early DNR status (within 24 hours of admission). MAIN OUTCOMES AND MEASURES In-hospital mortality, determined using hierarchical logistic regression. RESULTS A total of 90,644 pneumonia cases (5.4% of admissions) were identified among the 303 California hospitals evaluated during 2011; mean (SD) age of the patients was 72.5 (13.7) years, 51.5% were women, and 59.3% were white. Hospital DNR rates varied (median, 15.8%; 25th-75th percentile, 8.9%-22.3%). Without accounting for patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality (adjusted odds ratio [OR] for highest-quartile DNR rate vs lowest quartile, 1.17; 95% CI, 1.04-1.32), corresponding to worse hospital mortality rankings. In contrast, after accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, hospitals with higher DNR rates had lower mortality (adjusted OR for highest-quartile DNR rate vs lowest quartile, 0.79; 95% CI, 0.70-0.89), with reversal of associations between hospital mortality rankings and DNR rates. Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment. Hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia (r = 0.11; P = .052); however, DNR rates were positively correlated with patient satisfaction scores (r = 0.35; P < .001). CONCLUSIONS AND RELEVANCE Failure to account for DNR status may confound the evaluation of hospital quality using mortality outcomes, penalizing hospitals that admit a greater proportion of patients with limits on life-sustaining treatments. Stakeholders should seek to improve methods to standardize and report DNR status in hospital discharge records to allow further assessment of implications of adjusting for DNR in quality measures.
Collapse
Affiliation(s)
- Allan J Walkey
- The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Renda Soylemez Wiener
- The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts3Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedfo
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor 5Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Peter K Lindenauer
- Center for Quality of Care Research, Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts7Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| |
Collapse
|
27
|
Fendler TJ, Spertus JA, Kennedy KF, Chen LM, Perman SM, Chan PS. Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest. JAMA 2015; 314:1264-71. [PMID: 26393849 PMCID: PMC4701196 DOI: 10.1001/jama.2015.11069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts. OBJECTIVE To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis. DESIGN, SETTING, AND PARTICIPANTS Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (ie, without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined. EXPOSURES Do-not-resuscitate orders within 12 hours of ROSC. MAIN OUTCOMES AND MEASURES Likelihood of favorable neurological survival. RESULTS Overall, 5944 (22.6% [95% CI, 22.1%-23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P < .05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (P for both trends <.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI, 29.9%-31.1%]) than it was for those with DNR orders (1.8% [95% CI, 1.6%-2.0%]). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis. CONCLUSIONS AND RELEVANCE Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including those with the best prognosis.
Collapse
Affiliation(s)
- Timothy J Fendler
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Kevin F Kennedy
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Lena M Chen
- Department of Medicine, University of Michigan, Ann Arbor
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Paul S Chan
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| |
Collapse
|
28
|
Salottolo K, Offner PJ, Orlando A, Slone DS, Mains CW, Carrick M, Bar-Or D. The epidemiology of do-not-resuscitate orders in patients with trauma: a community level one trauma center observational experience. Scand J Trauma Resusc Emerg Med 2015; 23:9. [PMID: 25645242 PMCID: PMC4333154 DOI: 10.1186/s13049-015-0094-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/19/2015] [Indexed: 12/20/2022] Open
Abstract
Background Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients. Methods We included all adults with trauma to a community Level I Trauma Center over 6 years (2008–2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications). Results Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3–8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay. Conclusions Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0094-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kristin Salottolo
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Patrick J Offner
- Trauma Services Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Alessandro Orlando
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Denetta S Slone
- Trauma Services Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| | - Charles W Mains
- Trauma Services Department, St. Anthony Hospital, Lakewood, CO, 80228, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| | - Matthew Carrick
- Trauma Services Department, Medical Center of Plano, Plano, TX, 75075, USA.
| | - David Bar-Or
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| |
Collapse
|
29
|
Chao TH, Hsieh TJ, Wang V. "Do not resuscitate" orders among deceased patients who received acute neurological care: an observation analysis. Medicine (Baltimore) 2014; 93:e343. [PMID: 25546685 PMCID: PMC4602613 DOI: 10.1097/md.0000000000000343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
There were many reports about the "do not resuscitate" (DNR) order while practicing in the critical care units and conducting hospice affairs but limited in the neurological issues. This study investigated the possible flaws in the execution of the DNR order among patients who received acute neurological care in Taiwan. Over a 3-year period, we retrospectively reviewed the medical records of 77 deceased patients with neurological conditions for DNR orders. Registry and analysis works included demography, hospital courses, DNR data, and clinical usefulness of the lab and image examinations. Sixty-seven DNR orders were requested by the patients' families, and more than half were signed by the patients' children or grandchildren. The main DNR items were chest compression, cardiac defibrillation, and pacemaker use, although several DNR patients received resuscitation. The mean duration from the coding date to death was 7.6 days. Two-thirds of the patients with DNR requests remained in the intensive care unit, with a mean stay of 6.9 days. Several patients underwent regular roentgenography and blood tests on the day of their death, despite their DNR orders. Hospital courses and DNR items may be valuable information on dealing with the patients with DNR orders. The results of this study also suggest the public education about the DNR orders implemented for neurological illnesses.
Collapse
Affiliation(s)
- Tzu-Hao Chao
- From the School of Medicine, Fu Jen Catholic University (THC, VW); Department of Neurology (THC, VW), and Department of Family Medicine (TJH), Cardinal Tien, College of Medicine, Hospital, Xindian District, New Taipei City, Taiwan
| | | | | |
Collapse
|
30
|
Albaeni A, Chandra-Strobos N, Vaidya D, Eid SM. Predictors of early care withdrawal following out-of-hospital cardiac arrest. Resuscitation 2014; 85:1455-61. [PMID: 25201612 DOI: 10.1016/j.resuscitation.2014.08.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/18/2014] [Accepted: 08/21/2014] [Indexed: 01/12/2023]
Abstract
AIMS To identify factors that associated with early care withdrawal in out-of-hospital cardiac arrest patients. METHODS Data was collected from 189 survivors to hospital admission. Patients were classified by survival status upon hospital discharge, and those who died were categorized into withdrawal vs. no withdrawal of care. Those who had care withdrawn were further subdivided into early care withdrawal i.e. ≤72 h vs. late withdrawal >72 h. Multivariable adjusted odds ratios were used to assess factors associated with early care withdrawal. RESULTS Of 189 patients with cardiac arrest, only 36 had advanced directives (19%) and 99 (52%) had care withdrawn. Most patients whose care was withdrawn died in hospital (94/99, 95%), and the remainder died in hospice. Care was withdrawn early ≤72 h in the majority of patients (59/94, 63%). Median time to early care withdrawal was 2 days IQR (1-3). Factors associated with early care withdrawal were age ≥75 years, poor initial neurologic exam, multiple co morbidities, multi-organ failure, lactic acid ≥10 mmolL(-1), Caucasian race and absence of bystander CPR. Advance directives did not appear to determine early care withdrawal. CONCLUSIONS Although most cardiac arrest patients do not have advance directives, care is often withdrawn in more than 50% and in many before the accepted time for neurological awakening (72h). The decision to withdraw care is influenced by older age, race, preexisting co morbidities, multi-organ failure, and a poor initial neurological exam. Further studies are needed to better understand this phenomenon and other sociological factors that guide such decisions.
Collapse
Affiliation(s)
- Aiham Albaeni
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisha Chandra-Strobos
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|