From the Department of Neurology, University of Rochester Medical Center, NY (A.G.K., R.G.H.); and Stroke Program, University of Michigan Health Systems, Ann Arbor (D.B.Z., L.B.M., J.F.B.).
Stroke. 2014 Mar;45(3):822-7. doi: 10.1161/STROKEAHA.113.004573. Epub 2014 Feb 12.
Decisions on life-sustaining treatments and the use of do-not-resuscitate (DNR) orders can affect early mortality after stroke. We investigated the variation in early DNR use after stroke among hospitals in California and the effect of this variation on mortality-based hospital classifications.
Using the California State Inpatient Database from 2005 to 2011, ischemic stroke admissions for patients aged≥50 years were identified. Cases were categorized by the presence or the absence of DNR orders within the first 24 hours of admission. Multilevel logistic regression models with a random hospital intercept were used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors, and demographics. Hospital mortality rank order was assigned based on this model and compared with the results of a second model that included DNR status.
From 355 hospitals, 252,368 cases were identified, including 33,672 (13.3%) with early DNR. Hospital-level-adjusted use of DNR varied widely (quintile 1, 2.2% versus quintile 5, 23.2%). Hospitals with higher early DNR use had higher inpatient mortality because inpatient mortality more than doubled from quintile 1 (4.2%) to quintile 5 (8.7%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum, including among high mortality hospitals.
There is wide variation in the hospital-level proportion of ischemic stroke patients with early DNR orders; this variation affects hospital mortality estimates. Unless the circumstances of early DNR orders are better understood, mortality-based hospital comparisons may not reliably identify hospitals providing a lower quality of care.
对生命支持治疗的决策和使用“不复苏”（DNR）医嘱可能会影响中风后的早期死亡率。我们研究了加利福尼亚州各医院中风后早期使用 DNR 的差异，以及这种差异对基于死亡率的医院分类的影响。
使用 2005 年至 2011 年加利福尼亚州住院患者数据库，确定年龄≥50 岁的缺血性中风入院患者。根据入院后 24 小时内是否存在 DNR 医嘱将病例分为有/无 DNR 医嘱两组。采用多水平逻辑回归模型，以医院随机截距为预测变量，调整合并症、血管风险因素和人口统计学因素后，预测住院死亡率。根据该模型对医院死亡率进行排序，并与包含 DNR 状态的第二个模型的结果进行比较。
从 355 家医院中，共确定了 252368 例病例，其中 33672 例（13.3%）患者在早期使用了 DNR。医院层面 DNR 使用的调整后差异很大（五分位 1 为 2.2%，五分位 5 为 23.2%）。早期 DNR 使用较多的医院住院死亡率较高，因为住院死亡率从五分位 1（4.2%）到五分位 5（8.7%）增加了一倍以上。如果不调整 DNR 医嘱，就会导致整个等级范围内的医院大量重新分类，包括高死亡率医院。
各医院缺血性中风患者早期使用 DNR 医嘱的比例存在很大差异；这种差异会影响医院死亡率的估计。除非更好地了解 DNR 医嘱的情况，否则基于死亡率的医院比较可能无法可靠地识别提供较低护理质量的医院。
