Shepardson L B, Gordon H S, Ibrahim S A, Harper D L, Rosenthal G E
Division of General Internal Medicine and Health Care Research, Cleveland VA Medical Center, Ohio, USA.
J Gen Intern Med. 1999 Jan;14(1):15-20. doi: 10.1046/j.1525-1497.1999.00275.x.
To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample.
Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82-0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates.
In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p <.001). Rates of orders were also lower ( p <. 001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower ( p <.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days.
The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.
使用一个大型、多地点、基于社区的样本，比较非裔美国患者和白人患者中“不要复苏”（DNR）医嘱的使用情况。
我们的样本包括1993年至1995年期间，在一个大都市地区的30家医院连续收治的90821例患者，这些患者患有六种非手术疾病。人口统计学和临床数据从病历中提取。使用具有良好区分度的多变量风险调整模型（受试者操作特征曲线面积为0.82 - 0.88）来测量入院时的疾病严重程度。采用多因素逻辑回归分析来确定种族与DNR医嘱使用之间的独立关联，并对年龄、入院严重程度和其他协变量进行调整。
在所有患者中，非裔美国人的DNR医嘱使用率低于白人（9%对18%；p <.001）。在按年龄、性别、诊断、疾病严重程度和院内死亡分层的分析中，非裔美国人的医嘱率也较低（p <.001）。在对严重程度和其他重要协变量进行调整后，对于所有诊断，非裔美国人开具DNR医嘱的几率相对于白人仍然较低（p <.001），范围从阻塞性气道疾病的0.38到胃肠道出血的0.71。在仅限于入院第一天、第二天或第七天开具的医嘱的分析中，结果相似。最后，在开具DNR医嘱的患者中，非裔美国人在入院第一天开具医嘱的可能性较小，而在随后几天开具医嘱的可能性较大。
即使在对疾病严重程度和其他协变量进行调整后，非裔美国人中DNR医嘱的使用率仍显著低于白人。识别这些差异背后的因素将有助于我们更好地理解非裔美国患者和白人患者在护理期望方面的差异程度。
