Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
Acad Emerg Med. 2013 Apr;20(4):381-7. doi: 10.1111/acem.12112.
Early studies suggest that racial, economic, and hospital-based factors influence the do-not-attempt-resuscitation (DNAR) status of admitted patients, although it remains unknown how these factors apply to patients admitted through the emergency department (ED) and whether use is changing over time.
The objective was to examine patient and hospital attributes associated with DNAR orders placed within 24 hours of admission through the ED and changes in DNAR use over time.
This was a population-based, retrospective cross-sectional study of patients 65 years and older admitted to 367 acute care hospitals in California between 2002 and 2010; the subset of patients admitted through the ED formed the primary sample. The primary outcome was placement of a DNAR order within 24 hours of admission. Associations between DNAR order placement and hospital characteristics, patient demographics, and year were tested. Descriptive statistics are reported, and multivariable logistic regression models with generalized estimating equations (GEEs) were used to account for clustering within hospitals.
There were 9,507,921 patients older than 65 years admitted to 367 California hospitals over the 9-year period, of whom 1,029,335 (10.8%) had DNAR orders placed within 24 hours of admission; 83% of DNAR orders were placed for patients admitted through the ED. Among patients over 65 years admitted through the ED (n = 6,396,910), DNAR orders were used less frequently at teaching hospitals (9.5% vs. 13.7%), for-profit hospitals (8.6% vs. 14.6% nonprofit), nonrural hospitals (12.0% vs. 26.2%), and large hospitals (11.1% vs. 15.0% for hospitals in the smallest quartile for bed size; all p < 0.0001). In regression modeling adjusted for clustering and patient demographics, these trends persisted for all hospital types, except teaching hospitals. Decreased DNAR frequency was associated with race (African American odds ratio [OR] = 0.59, 95% confidence interval [CI] = 0.51 to 0.67; Asian OR = 0.70, 95% CI = 0.59 to 0.82; reference = white), ethnicity (Hispanic OR = 0.61, 95% CI = 0.55 to 0.68), sex (male OR = 0.90, 95% CI = 0.88 to 0.92), and MediCal insurance (OR = 0.70, 95% CI = 0.57 to 0.85). Statewide rates of DNAR steadily increased from 12.2% in 2002 to 14.3% in 2010, although this trend occurred primarily among white and Asian patients.
While statewide rates of DNAR use have increased over time among patients admitted through the ED, there is variable penetrance of this practice by hospital types, patient race, and patient ethnicity. These patterns may suggest barriers to end-of-life discussions, differences in hospital case mix, and variation in cultural or institutional beliefs and practices.
早期研究表明，种族、经济和医院因素会影响入院患者的不复苏（DNAR）状态，尽管尚不清楚这些因素如何适用于通过急诊部（ED）入院的患者，以及随着时间的推移使用情况是否发生变化。
本研究旨在调查患者和医院特征与通过 ED 入院后 24 小时内下达的 DNAR 医嘱之间的关系，以及 DNAR 使用随时间的变化。
这是一项基于人群的回顾性队列研究，研究对象为 2002 年至 2010 年期间在加利福尼亚州 367 家急性护理医院中年龄在 65 岁及以上的患者；通过 ED 入院的患者构成了主要样本。主要结局是在入院后 24 小时内下达 DNAR 医嘱。检验了 DNAR 医嘱下达与医院特征、患者人口统计学特征和年份之间的关联。报告描述性统计数据，并使用广义估计方程（GEE）的多变量逻辑回归模型来解释医院内的聚类效应。
在 9 年期间，加利福尼亚州的 367 家医院共收治了 9507921 名年龄在 65 岁以上的患者，其中 1029335 名（10.8%）在入院后 24 小时内下达了 DNAR 医嘱；83%的 DNAR 医嘱是为通过 ED 入院的患者下达的。在通过 ED 入院的 6396910 名 65 岁以上的患者中，DNAR 医嘱在教学医院（9.5% vs. 13.7%）、营利性医院（8.6% vs. 14.6%非营利）、非农村医院（12.0% vs. 26.2%）和大医院（11.1% vs. 15.0%对于床位规模最小的四分之一的医院；所有 p < 0.0001）使用频率较低。在调整聚类和患者人口统计学特征的回归模型中，除教学医院外，这些趋势在所有医院类型中均持续存在。DNAR 频率下降与种族（非裔美国人比值比[OR] = 0.59，95%置信区间[CI] = 0.51 至 0.67；亚裔 OR = 0.70，95% CI = 0.59 至 0.82；参考 = 白人）、族裔（西班牙裔 OR = 0.61，95% CI = 0.55 至 0.68）、性别（男性 OR = 0.90，95% CI = 0.88 至 0.92）和 MediCal 保险（OR = 0.70，95% CI = 0.57 至 0.85）有关。DNAR 的全州使用率从 2002 年的 12.2%稳步上升至 2010 年的 14.3%，尽管这一趋势主要发生在白人和亚裔患者中。
虽然通过 ED 入院的患者的 DNAR 使用比例随着时间的推移有所增加，但这种做法在医院类型、患者种族和患者族裔方面的普及程度存在差异。这些模式可能表明临终讨论存在障碍、医院病例组合存在差异以及文化或机构信仰和实践存在差异。
