VARIATION IN THE USE OF DO-NOT-RESUSCITATE ORDERS IN PATIENTS WITH STROKE

Objectives: To identify sociodemographic and clinical characteristics associated with the use of do-not-resuscitate (DNR) orders in hospital ized patients with stroke. To examine whether the use of DNR orders va ries across hospitals. Methods: This observational cohort study used d ata collected for 13 337 consecutive eligible patients with a primary diagnosis of stroke. These patients were discharged in 1991 through 19 94 from 30 hospitals in a large metropolitan area. Study data were abs tracted from patients' hospital records using standard forms. Admissio n severity of illness was measured using a validated multivariable mod el. Sociodemographic and clinical factors independently associated wit h the use of DNR orders were identified using stepwise logistic regres sion. Results: Do-not-resuscitate orders were written for 2898 patient s (22%). Patient characteristics independently (P<.01) associated with increased use of DNR orders included increasing age (odds ratio [OR], 1.06 per year); admission from a skilled nursing facility (OR, 2.44) or through the emergency department (OR, 1.49); cancer (OR, 2.73), int racerebral hemorrhage (OR, 2.12), coma (OR, 7.47), or lethargy or stup or on admission neurological assessment (OR, 3.38); and increasing adm ission severity (OR, 1.29 per decile). In contrast, African American r ace was associated with lower use of DNR orders (OR, 0.54). Although s ubstantial variation in the use of DNR orders was observed across hosp itals, with rates ranging from 12% to 32%, adjusting for the above pat ient characteristics eliminated much of this variation, including diff erences between major teaching and other hospitals and between hospita ls with and without religious affiliations. Conclusions: In our commun ity-based analysis of patients with stroke, the use of DNR orders was common and was strongly related to several patient characteristics. Th ese factors explained much of the variation across hospitals. While ou r analysis did not account for differences in patient preferences for treatment, the differences we observed in the use of DNR orders across sociodemographic groups are suggestive of variations in care and may have important implications for the cost and quality of hospital care.