Do-not-resuscitate orders and predictive models after intracerebral hemorrhage.
OBJECTIVE
To quantify the accuracy of commonly used intracerebral hemorrhage (ICH) predictive models in ICH patients with and without early do-not-resuscitate orders (DNR).


METHODS
Spontaneous ICH cases (n = 487) from the Brain Attack Surveillance in Corpus Christi study (2000-2003) and the University of California, San Francisco (June 2001-May 2004) were included. Three models (the ICH Score, the Cincinnati model, and the ICH grading scale [ICH-GS]) were compared to observed 30-day mortality with a chi(2) goodness-of-fit test first overall and then stratified by early DNR orders.


RESULTS
Median age was 71 years, 49% were female, median Glasgow Coma Scale score was 12, median ICH volume was 13 cm(3), and 35% had early DNR orders. Overall observed 30-day mortality was 42.7% (95% confidence interval [CI] 38.3-47.1), with the average model-predicted 30-day mortality for the ICH Score, Cincinnati model, and ICH-GS at 39.9% (p = 0.005), 40.4% (p = 0.007), and 53.9% (p < 0.001). However, for patients with early DNR orders, the observed 30-day mortality was 83.5% (95% CI 78.0-89.1), with the models predicting mortality of 64.8% (p < 0.001), 57.2% (p < 0.001), and 77.8% (p = 0.02). For patients without early DNR orders, the observed 30-day mortality was 20.8% (95% CI 16.5-25.7), with the models predicting mortality of 26.6% (p = 0.05), 31.4% (p < 0.001), and 41.1% (p < 0.001).


CONCLUSIONS
ICH prognostic model performance is substantially impacted when stratifying by early DNR status, possibly giving a false sense of model accuracy when DNR status is not considered. Clinicians should be cautious when applying these predictive models to individual patients.
Zahuranec
D B
DB
University of Michigan Cardiovascular Center, 1500 East Medical Center Drive, SPC#5855, Ann Arbor, MI 48109-5855, USA. zdarin@umich.edu
Morgenstern
L B
LB
Sánchez
B N
BN
Resnicow
K
K
White
D B
DB
Hemphill
J C
JC
D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000453:epidemiology / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D016009:Chi-Square Distribution; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D011237:Predictive Value of Tests; D012372:ROC Curve; D016414:Resuscitation Orders; D012189:Retrospective Studies; D012720:Severity of Illness Index