Dataset Information

Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke.

ABSTRACT: Background and Purpose- Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods- Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an interaction term added to allow separate hazard ratios for early (?24 hours) and late (>24 hours) DNR. Stroke type-specific calendar trends were assessed with an interaction term between calendar year (linear) and stroke type. Results- Two thousand six hundred seventy-two cases were included (ICH, 14%). Mean age was 69, 50% were female, and race-ethnicity was Mexican American (58%), non-Hispanic white (37%), and African American (5%). Overall, 16% had a DNR order during the hospitalization. For ICH, DNR orders (early and late) were stable over the study period. However, early DNR orders became more common over time after ischemic stroke (hazard ratio for 2016 versus 2007: 1.89; 95% CI, 1.06-3.39), with no change over time for late DNR orders after ischemic stroke. Mexican Americans (hazard ratio, 0.65; 95% CI, 0.50-0.86) and African Americans (hazard ratio, 0.17; 95% CI, 0.04-0.71) were less likely than non-Hispanic whites to have early DNR orders, though there were no race-ethnic differences in late DNR orders. There was no change in race-ethnic difference in DNR orders over the time of the study (interaction P>0.60). Conclusions- Despite revised national guidelines cautioning against early DNR orders in ICH, presence of DNR orders after ICH was stable between 2007 and 2016, with only slight increases in early DNR orders after ischemic stroke. Mexican Americans and African Americans remain less likely than non-Hispanic whites to have early DNR orders after stroke.

SUBMITTER: Bailoor K

PROVIDER: S-EPMC6597008 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke.

Bailoor Kunal K Shafie-Khorassani Fatema F Lank Rebecca J RJ Case Erin E Garcia Nelda M NM Lisabeth Lynda D LD Sánchez Brisa N BN Kim Sehee S Morgenstern Lewis B LB Zahuranec Darin B DB

Stroke 20190610 7

Background and Purpose- Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods- Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an inte ...[more]

PMID: 31177986

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Project description:Although do-not-resuscitate orders only prohibit cardiopulmonary resuscitation in the case of cardiac arrest, the common initiation of this code status in the context of end-of-life care may lead providers to draw premature conclusions about other goals of care. The aim of this study is to identify concerns regarding care quality in the setting of do-not-resuscitate orders within the Department of Defense and compare differences in perceptions between members of the critical care team.DesignA cross sectional observational study was conducted.SettingThis study took place in the setting of critical care within the Department of Defense.SubjectsAll members of the Uniformed Services Section of the Society of Critical Care Medicine were invited to participate.InterventionsA validated 31-question survey exploring the perceptions of care quality in the setting of do-not-resuscitate status was distributed.Measurements and main resultsExploratory factor analysis was used to categorically group survey questions, and average factor scores were compared between respondent groups using t tests. Responses to individual questions were also analyzed between comparison groups using Fisher exact tests. Factor analysis revealed no significant differences between respondents of different training backgrounds; however, those with do-not-resuscitate training were more likely to agree that active treatment would be pursued (p = 0.024) and that trust and communication would be maintained (p = 0.005). Although 38% of all respondents worry that quality of care will decrease, 93% agree that life-prolonging treatments should be offered. About a third of providers wrongly believed that a do-not-resuscitate order must be reversed prior to an operation.ConclusionsAlthough providers across training backgrounds held similar concerns about decreased care quality in the ICU, there is wide belief that the routine and noninvasive interventions are offered as indicated. Those with do-not-resuscitate training were more likely to believe that standards of care continued to be met after code status change.

Project description:Background and Purpose- An excess incidence of strokes among blacks versus whites has been shown, but data on disparities related to Hispanic ethnicity remain limited. This study examines race/ethnic differences in stroke incidence in the multiethnic, largely Caribbean Hispanic, NOMAS (Northern Manhattan Study), and whether disparities vary by age. Methods- The study population included participants in the prospective population-based NOMAS, followed for a mean of 14±7 years. Multivariable-adjusted Cox proportional hazards models were constructed to estimate the association between race/ethnicity and incident stroke of any subtype and ischemic stroke, stratified by age. Results- Among 3298 participants (mean baseline age 69±10 years, 37% men, 24% black, 21% white, 52% Hispanic), 460 incident strokes accrued (400 ischemic, 43 intracerebral hemorrhage, 9 subarachnoid hemorrhage). The most common ischemic subtype was cardioembolic, followed by lacunar infarcts, then cryptogenic. The greatest incidence rate was observed in blacks (13/1000 person-years), followed by Hispanics (10/1000 person-years), and lowest in whites (9/1000 person-years), and this order was observed for crude incidence rates until age 75. By age 85, the greatest incidence rate was in Hispanics. Blacks had an increased risk of stroke versus whites overall in multivariable models that included sociodemographics (hazard ratio, 1.51 [95% CI, 1.13-2.02]), and stratified analyses showed that this disparity was driven by women of age ≥70. The increased rate of stroke among Hispanics (age/sex-adjusted hazard ratio, 1.48 [95% CI, 1.13-1.93]) was largely explained by education and insurance status (a proxy for socieoeconomic status; hazard ratio after further adjusting for these variables, 1.17 [95% CI, 0.85-1.62]) but remained significant for women age ≥70. Conclusions- This study provides novel data regarding the increased stroke risk among Caribbean Hispanics in this elderly population. Results highlight the need to create culturally tailored campaigns to reach black and Hispanic populations to reduce race/ethnic stroke disparities and support the important role of low socioeconomic status in driving an elevated risk among Caribbean Hispanics.

Dataset Information

Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke.

Publications

Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke.

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