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Abstract
Objective: There is concern that do-not-resuscitate (DNR) orders may lead to stroke patients receiving less aggressive treatment and poorer care. Our objectives were to assess the relationship between DNR orders and quality of stroke care among veterans.
Methods: A cohort of 3,965 acute ischemic stroke patients admitted to 131 Veterans Health Administration (VHA) facilities in fiscal year 2007 underwent chart abstraction. DNR codes were identified through electronic orders or by documentation of “no code,” “no cardiopulmonary resuscitation,” or “no resuscitation.” Quality of care was measured using 14 inpatient ischemic stroke quality indicators. The association between DNR orders and quality indicators was examined using multivariable logistic regression.
Results: Among 3,965 ischemic stroke patients, 535 (13.5%) had DNR code status, 71% of whom had orders first documented within 1 day of admission. Overall, 4.9% of patients died in-hospital or were discharged to hospice; these outcomes were substantially higher in patients with DNR orders (29.7%), particularly if they were not documented until ≥2 days after admission (47.1%). Patients with DNR orders were significantly older, had more comorbidities, and had greater stroke severity. Following adjustment there were few significant associations between DNR status and the 14 quality indicators, with the exception of lower odds of early ambulation (odds ratio = 0.58, 95% confidence interval = 0.41–0.81) in DNR patients.
Conclusions: DNR orders were associated with limited differences in the select quality indicators investigated, which suggests that DNR orders did not impact quality of care. However, whether DNR orders influence treatment decisions that more directly affect survival remains to be determined.
GLOSSARY
- AF=
- atrial fibrillation;
- APACHE III=
- modified Acute Physiology and Chronic Health Evaluation;
- CMO=
- comfort measures only;
- DNR=
- do-not-resuscitate;
- FY=
- fiscal year;
- HD=
- hospital day;
- NIHSS=
- NIH Stroke Scale;
- OQP=
- Office of Quality and Performance;
- QI=
- quality indicator;
- tPA=
- tissue plasminogen activator;
- VHA=
- Veterans Health Administration
Footnotes
Study funding: The Department of Veterans Affairs, Veterans Health Administration (VHA), Office of Quality and Performance, Health Services Research and Development Service, Quality Enhancement Research Initiative (RRP 09-184) supported this project (Dr. Bravata, principal investigator).
Supplemental data at www.neurology.org
- Received March 11, 2012.
- Accepted July 4, 2012.
- Copyright © 2012 by AAN Enterprises, Inc.
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