Abstract
Nontraumatic intracerebral hemorrhage (ICH) is associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders are linked to poorer outcomes in patients with ICH, possibly due to less active management. Demographic, regional, and social factors, not related to ICH severity, have not been adequately looked at as significant predictors of DNR utilization. We reviewed the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database in 2011 for adult ICH admissions and DNR status. We generated hierarchical 2-level multivariate regression models to estimate adjusted odds ratios. We analyzed 25 768 ICH hospitalizations, 18% of which (4620 hospitalizations) had DNR orders, corresponding to national estimates of 126 254 and 22 668, respectively. In multivariable regression, female gender, white or Hispanic/Latino ethnicity, no insurance coverage, and teaching hospitals were significantly associated with increased DNR utilization after adjusting for confounders. There was also significantly more interhospital variability in the lowest quartile of hospital volume. In conclusion, demographic factors and insurance status are significantly associated with increased DNR utilization, with more individual hospital variability in low-volume hospitals. The reasons for this are likely qualitative and linked to patient, provider, and hospital practices.
Keywords: intracranial hemorrhages, cerebrovascular disorders, stroke, neurohospitalist, clinical specialty, outcomes, techniques
Introduction
Cerebrovascular disease is the fifth most common cause of mortality in the United States, with 130 000 deaths annually.1 Spontaneous intracerebral hemorrhage (ICH) is the second most common cause of stroke, with high mortality and morbidity rates.2 Although there are many factors that affect patient outcomes, there is increasing focus on the role of do-not-resuscitate (DNR) orders on clinical outcomes and quality of care. Recent studies have demonstrated that DNR orders may lead to less active management and poorer quality of care causing worse outcomes.3,4
Do-not-resuscitate orders are implemented based on the wishes of the patient, family, or guardian, often after consultation with the physician, with the ultimate goal to respect the decision maker’s wishes regarding end of life. Therefore, the threshold for such a decision varies individually, but the effect of such a decision can collectively influence attitudes of care and have a ripple effect beyond the individual patient level.5
The factors affecting DNR order utilization are poorly understood because of the heterogeneity of influences and the subjectivity of the decision. We aimed to explore predictors and variability of DNR order utilization independent of disease severity in ICH hospitalizations.
Methods
Nationwide Inpatient Sample (NIS) is part of a family of databases and software tools developed for the Healthcare Cost and Utilization Project (HCUP). Healthcare Cost and Utilization Project databases and supplemental files are available to purchase online through the HCUP Central Distributor. We reviewed the HCUP’s NIS database in 2011 for adult ICH admissions using diagnosis code 431.xx. Data from 46 states were included in the database with data from 4941 hospitals.6 This study used the NIS, a deidentified patient database. Therefore, this study did not require institutional review board review in accordance with the Code of Federal Regulations, 45 CFR 46.
We defined DNR status with International Classification of Diseases (ICD) code—V49.86 as a secondary diagnosis and estimated severity by the All Patient Refined Diagnosis–Related Group (APR DRG) classification.7 The ICD codes used to define cerebral herniation, hemiplegia, cerebral edema, and ventilator use were 348.4, 342.xx, 348.5, and 96.72, respectively. Metastatic cancer was defined using the ICD codes, 196.0-199.1, as defined by the AHRQ (version 2) comorbidity software.6 We generated a hierarchical 2-level multivariate regression model to estimate adjusted odds ratios (OR) for DNR utilization predictors. We assessed predictor variables including patient demographics (age, sex, and ethnicity), hospital location (rural vs urban), hospital status (teaching vs nonteaching), hospital region (Northeast, Midwest or North Central, South, and West), APR DRG, insurance status (Medicare vs self- or no-pay vs private insurance), and confounders for ICH severity (cerebral edema/herniation, ventilator use, and hemiplegia). We divided hospitals into quartiles based on the volume of ICH admissions and then assessed heterogeneity within quartiles by calculating interclass correlation (ICC) and median OR (MOR). We considered a 2-tailed P value of <.05 to be significant. We utilized SAS 9.3 (SAS Institute Inc, Cary, North Carolina) for all analyses.
Results
We analyzed 25 768 patients with ICH (weighted national estimate [WNE] 126 254 patients), 18% of which (4620 patients; WNE 22 668) had DNR orders. In multivariable regression analysis, older age, female gender, insurance (self- or no-pay compared to private insurance), diagnoses (metastatic cancer/cerebral herniation), and the highest quartile of income were significantly associated with greater DNR utilization. In contrast, black and Hispanic/Latino ethnicity and hospital teaching status were associated with lower utilization (Table 1).
Table 1.
Multivariable Logistic Regression of Significant Predictors of DNR Utilization.
| Odds Ratio (95% Confidence Interval) | P | |
|---|---|---|
| Age | ||
| <65 Years | Ref | |
| ≥65 Years | 2.82 (2.61-3.04) | <.001 |
| Sex | ||
| Male | Ref | |
| Female | 1.21 (1.14-1.27) | <.001 |
| Race | ||
| White | Ref | |
| Black | 0.59 (0.53-0.64) | <.001 |
| Hispanic | 0.71 (0.64-0.79) | <.001 |
| Others | 0.73 (0.66-0.82) | <.001 |
| APR DRG Severity Scale | ||
| Minor or moderate risk | Ref | |
| Major risk | 1.78 (1.66-1.90) | <.001 |
| Extreme risk | 1.86 (1.72-2.01) | <.001 |
| Concurrent diagnosis | ||
| Metastatic cancer | 1.93 (1.68-2.23) | <.001 |
| Cerebral herniation | 2.52 (2.30-2.75) | <.001 |
| Median household income category by ZIP | ||
| 0-25th Percentile | Ref | |
| 26-50th Percentile | 1.00 (0.92-1.08) | .992 |
| 51-75th Percentile | 1.07 (0.99-1.17) | .101 |
| 76-100th Percentile | 1.12 (1.02-1.23) | .022 |
| Hospital region | ||
| Northeast | Ref | |
| Midwest or North Central | 0.72 (0.42-1.25) | .240 |
| South | 0.64 (0.40-1.03) | .064 |
| West | 0.90 (0.53-1.52) | .699 |
| Hospital teaching status | ||
| Nonteaching | Ref | |
| Teaching | 0.66 (0.46-0.95) | .025 |
| Hospital bed size | ||
| Small | Ref | |
| Medium | 1.26 (0.74-2.15) | .390 |
| Large | 1.56 (0.95-2.57) | .078 |
| Primary payer | ||
| Private (including HMO) | Ref | |
| Medicare/Medicaid | 1.08 (0.99-1.18) | .069 |
| Self-pay/no charge/ other | 1.16 (1.03-1.30) | .017 |
Abbreviations: APR DRG, All Patient Refined Diagnosis–Related Group; DNR, do-not-resuscitate; HMO, Health Maintenance Organization.
On analysis of quartiles by ICH volume, ICC and MOR were highest in the lowest quartile but did not differ significantly between the other quartiles (Table 2 and Figure 1). Thus, a patient admitted for ICH in a first quartile hospital had 6.8 times odds of having DNR orders than if admitted at another first-quartile hospital. This demonstrates significant heterogeneity for DNR utilization within the hospitals with the lowest quartile of ICH volume.
Table 2.
Interclass Correlation and Median Odds Ratio by Quartiles of ICH Hospitalization Volume.
| ICH Hospital Volume | ICC (95% CI) | MOR |
|---|---|---|
| Fourth (lowest) quartile | 0.55 (0.53-0.58) | 6.83 (6.13-7.55) |
| Third quartile | 0.26 (0.22-0.30) | 2.8 (2.49-3.10) |
| Second quartile | 0.26 (0.20-0.31) | 2.79 (2.39-3.19) |
| First (top) quartile | 0.34 (0.21-0.43) | 3.45 (2.42-4.53) |
Abbreviations: CI, confidence interval; ICC, interclass correlation; ICH, intracerebral hemorrhage; MOR, median odds ratio.
Figure 1.
Mean odds ratio of do-not-resuscitate (DNR) utilization by quartiles of hospitals. The quartiles were created by intracerebral hemorrhage (ICH) volume.
Discussion
Literature on factors that may affect DNR utilization has focused on age and severity of ICH.8 Data on other possible predictors of DNR utilization that are not related to severity of ICH or underlying comorbidities are limited. A single-hospital experience assessed the impact of ethnicity and social factors on DNR utilization in 1988.9 Results from a single-center study in Sweden resulted in age (≥ 75 years), former stroke, Reaction Level Scale grades 2-3 and 4, and the presence of intraventricular hemorrhage as independent predictors of DNR utilization.10 Another single-center study found gender to be predictive of early DNR utilization, with women being more likely to receive early DNR orders.11
To the best of our knowledge, our study is the first to demonstrate that demographic factors and insurance status play a significant role in DNR utilization in ICH admissions in a large, nationally representative inpatient sample.
Our analysis shows, understandably, that older and sicker patients have a greater rate of DNR utilization. It further indicates that DNR utilization rates are the highest in uninsured patients in teaching centers, with least variability of results in hospitals with large volume. The reasons for this are likely multifactorial, qualitative, and linked to patient, provider, and hospital practices.
It seems likely that finances play a role in patients making this decision, with uninsured patients and families choosing DNR utilization. Moreover, it could be that patients in large teaching hospitals are better informed about their health status and therefore are more confident about such decisions. Our analysis also shows lower rates of DNR utilization in the African Americans as compared to whites, even after accounting for the severity of illness. This has been shown before in a large retrospective hospital-based cohort. This could be hypothesized to a difference in expectation in inpatient care.12
Our study is limited by the use of administrative data and lack of in-depth exploration of reasons for this discrepancy and any explanation of these results is, at best, speculative. The DNR order utilization has been linked to variation in the quality of care.3,4 In such a scenario, factors affecting DNR utilization could therefore be associated with heterogeneity in patient care. Further objective exploration and the understanding of the factors leading to this decision can help us not only improve outcomes but also possibly provide better care.
Patient care and decision making in critical conditions call for a fine balance between realistic expectations, patient wishes, family attitudes, social mores, and negativism toward outcomes. While the ultimate moral and legal right to make the final decision rests with the patient and/or the family, such a decision can be empowered with information, thereby helping them make an informed choice.
Footnotes
Authors’ Note: Patel, Mahajan, Kar, Benjo, Sinha, Pathak and Nadkarni contributed to study concept and design. Annapureddy, Agarwal, Jani, Sinha, Pakanati, Konstantinidis, and Benjo contributed to the acquisition of data. Simoes, Sinha Konstantinidis, Pakanati, and Mahajan contributed to analysis and interpretation of data. Patel, Mahajan, Sinha, Simoes, and Nadkarni contributed to drafting of the manuscript. Annapureddy, Agarwal, Pakanati, Jani, Sinha, Simoes, Konstantinidis, Nadkarni, and Benjo contributed to critical revision of the manuscript for important intellectual content. Patel, Mahajan, Benjo, and Nadkarni contributed to statistical analysis. Annapureddy, Agarwal, Jani, Konstantinidis, Pathak and Benjo contributed to administrative, technical, and material support. Konstantinidis and Nadkarni contributed to study supervision.
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
References
- 1. Centers for Disease Control and Prevention: Stroke statistics. 2015. Web site http://www.cdc.gov/stroke/facts.htm. Updated March 24, 2015. Accessed April 8, 2015.
- 2. Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke J Cereb Circ. 2007;38:2001–2023. [DOI] [PubMed] [Google Scholar]
- 3. Reeves MJ, Myers LJ, Williams LS, Phipps MS, Bravata DM. Do-not-resuscitate orders, quality of care, and outcomes in veterans with acute ischemic stroke. Neurology. 2012;79(19):1990–1996. [DOI] [PubMed] [Google Scholar]
- 4. Silvennoinen K, Meretoja A, Strbian D, Putaala J, Kaste M, Tatlisumak T. Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage. Int J Stroke. 2014;9(1):53–58. [DOI] [PubMed] [Google Scholar]
- 5. Hemphill JC. Do-not-resuscitate orders, unintended consequences, and the ripple effect. Crit Care Lond Engl. 2007;11(2):121. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Elixhauser A, Steiner C, Kruzikas D. Comorbidity Software Documentation. 2004. HCUP Methods Series Report # 2004-1. ONLINE February 6, 2004. U.S. Agency for Healthcare Research and Quality. Available: http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp. Accessed June, 2014.
- 7. Baram D, Daroowalla F, Garcia R, et al. Use of the All Patient Refined-Diagnosis Related Group (APR-DRG) Risk of Mortality Score as a Severity Adjustor in the Medical ICU. Clin Med Circ Respir Pulm Med. 2008;2:19–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Hakim RB, Teno JM, Harrell FE, et al. Factors associated with do-not-resuscitate orders: patients’ preferences, prognoses, and physicians’ judgments. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Ann Intern Med. 1996;125(4):284–293. [DOI] [PubMed] [Google Scholar]
- 9. Thompson BL, Lawson D, Croughan-Minihane M, Cooke M. Do patients’ ethnic and social factors influence the use of do-not-resuscitate orders? Ethn Dis. 1999;9(1):132–139. [PubMed] [Google Scholar]
- 10. Brizzi M, Abul-Kasim K, Jalakas M, Selariu E, Pessah-Rasmussen H, Zia E. Early do-not-resuscitate orders in intracerebral haemorrhage; frequency and predictive value for death and functional outcome. A retrospective cohort study. Scand J Trauma Resusc Emerg Med. 2012;20:36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Nakagawa K, Vento MA, Seto TB, et al. Sex differences in the use of early do-not-resuscitate orders after intracerebral hemorrhage. Stroke. 2013;44(11):3229–3231. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Shepardson LB, Gordon HS, Ibrahim SA, Harper DL, Rosenthal GE. Racial variation in the use of do-not-resuscitate orders. J Gen Intern Med. 1999;14(1):15–20. [DOI] [PMC free article] [PubMed] [Google Scholar]