ASSOCIATIONS BETWEEN THE USE OF DO-NOT-RESUSCITATE ORDERS AND LENGTH OF STAY IN PATIENTS WITH STROKE

OBJECTIVES. The study sought to describe the association between do-no t-resuscitate (DNR) orders and length of hospital stay (LOS), and how the association varies according to in-hospital mortality, timing of t he DNR order, and admission severity of illness. METHODS. The authors conducted a retrospective cohort analysis involving standardized revie w of patients' medical records. The study was performed at 30 acute ca re hospitals in a large metropolitan area. The authors studied the dat a of 13,337 consecutive patients with a primary diagnosis of stroke di scharged in 1991 through 1994. RESULTS. Do-not-resuscitate orders were written for 22% (n = 2,898) of the sample. In all patients, mean LOS was longer in patients with DNR orders than in patients without orders (12.0 versus 9.5 days; P < 0.001). A series of Cox regression analyse s were performed to adjust LOS for admission severity of illness and o ther covariates. In analyses of patients discharged alive (n = 12,011) , LOS was similar in patients with DNR orders written on days 1 to 2 c ompared with patients without DNR orders. However, LOS was longer in p atients with DNR orders written on days 3 to 7 (Hazard Ratio [HR], 1.5 9; 95% CI, 1.43-1.77) and on day 8 or later (HR, 2.72; 95% CI, 2.34-3. 16). In analyses of patients who died (n = 1,326), LOS was shorter for patients with DNR orders written on days I and 2 (HR, 0.59; 95% CI, 0 .49-0.71) than for patients without DNR orders but was longer among pa tients with DNR orders written on day 8 or later (HR, 2.58; 95% CI, 2. 06-3.22). In analyses stratified by admission severity, the relative e ffect of a DNR order tended to be less in patients with higher severit y. CONCLUSIONS. The relationship between DNR orders and LOS is complex and varies according to in-hospital mortality, the timing of the DNR order, and admission severity of illness. These findings highlight the importance of explicitly accounting for such factors in studies evalu ating the implications of DNR orders on the costs of hospital care.