A National Perspective of Do-Not-Resuscitate Order Utilization Predictors in Intracerebral Hemorrhage

Area of Science:

• Neurology
• Public Health
• Health Services Research

Background:

• Nontraumatic intracerebral hemorrhage (ICH) leads to significant patient morbidity and mortality.
• Do-not-resuscitate (DNR) orders are associated with worse outcomes in ICH patients, potentially due to less aggressive management.
• Predictors of DNR utilization beyond ICH severity, such as demographic and social factors, require further investigation.

Purpose of the Study:

• To investigate demographic, regional, and social factors influencing do-not-resuscitate (DNR) order utilization in adult patients with nontraumatic intracerebral hemorrhage (ICH).
• To identify significant predictors of DNR status in ICH hospitalizations, independent of clinical severity.

Main Methods:

• Analysis of the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database for 2011 adult ICH admissions.
• Utilized hierarchical 2-level multivariate regression models to determine adjusted odds ratios for DNR utilization.
• Examined associations between demographic characteristics, insurance status, hospital type, and DNR orders.

Main Results:

• Out of 25,768 analyzed ICH hospitalizations, 18% (4,620) had DNR orders.
• Female gender, White or Hispanic/Latino ethnicity, lack of insurance, and teaching hospitals were significantly associated with increased DNR utilization.
• Hospitals with lower patient volumes exhibited greater variability in DNR utilization rates.

Conclusions:

• Demographic factors and insurance status are significant predictors of increased DNR utilization in nontraumatic ICH.
• Hospital characteristics, particularly volume, influence DNR order variability.
• Qualitative factors related to patient, provider, and hospital practices likely explain these associations.