title: Variation in do-not-resuscitate orders for patients with ischemic stroke: implications for national hospital comparisons.
abstract: OBJECTIVE
  Decisions on life-sustaining treatments and the use of do-not-resuscitate (DNR) orders can affect early mortality after stroke. We investigated the variation in early DNR use after stroke among hospitals in California and the effect of this variation on mortality-based hospital classifications.
  
  
  METHODS
  Using the California State Inpatient Database from 2005 to 2011, ischemic stroke admissions for patients aged≥50 years were identified. Cases were categorized by the presence or the absence of DNR orders within the first 24 hours of admission. Multilevel logistic regression models with a random hospital intercept were used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors, and demographics. Hospital mortality rank order was assigned based on this model and compared with the results of a second model that included DNR status.
  
  
  RESULTS
  From 355 hospitals, 252,368 cases were identified, including 33,672 (13.3%) with early DNR. Hospital-level-adjusted use of DNR varied widely (quintile 1, 2.2% versus quintile 5, 23.2%). Hospitals with higher early DNR use had higher inpatient mortality because inpatient mortality more than doubled from quintile 1 (4.2%) to quintile 5 (8.7%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum, including among high mortality hospitals.
  
  
  CONCLUSIONS
  There is wide variation in the hospital-level proportion of ischemic stroke patients with early DNR orders; this variation affects hospital mortality estimates. Unless the circumstances of early DNR orders are better understood, mortality-based hospital comparisons may not reliably identify hospitals providing a lower quality of care.
authors: From the Department of Neurology, University of Rochester Medical Center, NY (A.G.K., R.G.H.); and Stroke Program, University of Michigan Health Systems, Ann Arbor (D.B.Z., L.B.M., J.F.B.).
authors: Adam G
authors: AG
authors: Kelly
authors: Darin B
authors: DB
authors: Zahuranec
authors: Robert G
authors: RG
authors: Holloway
authors: Lewis B
authors: LB
authors: Morgenstern
authors: James F
authors: JF
authors: Burke
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000401:mortality; D002140:California / Q000453:epidemiology; D015897:Comorbidity; D003627:Data Interpretation, Statistical; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006761:Hospitals; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D008297:Male; D015233:Models, Statistical; D011787:Quality of Health Care; D016414:Resuscitation Orders; D012307:Risk Factors; D012959:Socioeconomic Factors; D020521:Stroke / Q000401:mortality; D016896:Treatment Outcome
keywords: mortality; outcome assessment (health care); resuscitation orders; stroke