Abstract 92: Demographic, Regional and Social Predictors of Do Not Resuscitate Order Utilization in Intracerebral Hemorrhage: A National Perspective

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Vishal B Jani ◽  
Achint Patel ◽  
Girish Nadkarni ◽  
Alexandre Benjo ◽  
Narender Annapureddy ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Private Insurance ◽  
Female Gender ◽  
P Value ◽  
Weighted Estimate ◽  
Do Not Resuscitate ◽  
Discrimination Power ◽  
Social Predictors ◽  
North East ◽  
Dnr Orders

Background: Non-traumatic Intracerebral hemorrhage (ICH) is a life-threatening condition associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders have recently linked to poor outcomes in ICH patients probably due to the inactive management associated with these orders. Hypothesis: We tested the hypothesis that demographic, regional and social factors not related to ICH severity are significant predictors of DNR utilization. Methods: We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2011-2012 for ICH admissions in patients >18 years using the ICD 9-CM code 431. We defined DNR status with ICD code - V49.86 entered during the same admission as a secondary diagnosis and estimated severity of illness by the 3M™ All Patient Refined DRG (APR DRG) classification System. A hierarchical two level multivariate regression model were generated to estimate odds ratios (OR) for predictors of DNR utilization and discrimination power of models was assessed using C statistics. We considered a two tailed p value of <0.01 to be significant. Results: We analyzed 25768 pts (weighted estimate 126254) with ICH out of which 4620 (18%) pts (weighted estimate 22668) had DNR orders placed. In multivariable regression analysis, female gender (OR 1.2, 95% CI 1.2-1.3), Ethnicity [White(OR 1.6, 95% CI 1.5-1.7) and Hispanic(OR 1.2, 95% CI 1.1-1.3) compared to Black], Insurance [Medicare (OR 1.1, 95% CI 1.1-1.2) and self or no pay (OR 1.1, 95% CI 1.0-1.2) compared to private insurance], Hospital location [West (OR 1.6, 95% CI 1.2-2.1) compared to North-East ] were significantly associated with high DNR utilization rates after adjusting for patient level, hospital level characteristics, APR DRG severity scale and other clinical characteristics. Conclusions: In conclusion, demographic (female gender/ethnicity), social (insurance status) and regional (hospital location) are significantly associated with increased DNR utilization. The reasons for this are likely multifactorial, qualitative, linked to both patient and provider practices and need to be explored in more detail.

Abstract 20050: Impact of Median Household Income and Hospital Variation in the Utilization of Do-not-resuscitate Order in Cardiac Arrest: A National Perspective

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sopan Lahewala ◽  
Shantanu Solanki ◽  
Neil Patel ◽  
Nileshkumar J Patel ◽  
Achint Patel ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Household Income ◽  
Female Gender ◽  
P Value ◽  
Median Household Income ◽  
Do Not Resuscitate ◽  
Discrimination Power ◽  
Hospital Variation ◽  
Significant Difference ◽  
Vast Variation

Background: The factors determining DNR status in patients (pts) with cardiac arrest have not been well elucidated. Objective: The goal of our study was to assess impact of median household income and inter-hospital variation in utilization of DNR in Cardiac arrest. Methods: We queried the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database from 2011 using the ICD-9-CM code for cardiac arrest (427.5) as principal diagnosis. We defined pts’ DNR status with ICD code - V49.86 as a secondary diagnosis. Pts with age < 18 were excluded. NIS represents 20% of all US hospital pts. We built a hierarchical two level model adjusted for multiple confounding factors. Discrimination power of models was assessed using c statistics. Inter class correlation (ICC) and Median Odds Ratio (MOR) were generated from the hierarchical model. Results: We identified 1854 pts (weighted: 8915) with cardiac arrest across 1854 hospitals in the US, out of which 1.87% pts (366 pts, weighted: 1755) opted for DNR. Pts with higher median household income had decreased utilization of DNR (OR, 95% CI, P-Value) in 4th quartile: 0.59, 0.45-0.78, p<0.001, as compared to all other quartile. Also, with every 10 year increase in age, the rate of DNR increased (1.25, 1.18-1.32, p < 0.001). There was no statistically significant difference in other variables such as female gender, weekend admission, insurance type, teaching status of the hospital or hospital volume. C-statistics of model to generate ICC and MOR was 0.90. ICC was 60.6, which indicates that approximately 60.6 % of variation in utilization of DNR was attributable to the behavior of individual hospitals, and MOR was 8.5 which indicates that a randomly selected patient receiving DNR at a particular hospital would have approximately 9-fold higher odds of receiving DNR than an identical patient at a different randomly selected hospital. Conclusion: Our study highlights vast variation in utilization of DNR in randomly selected 2 different hospitals with cardiac arrest pts. It also indicates a disparity in utilization of DNR orders in Pts with higher median household income as compared to lower household income.

Abstract 19627: A National Perspective of the Influence of Do-Not-Resuscitate Orders on In-Hospital Mortality and Adverse Outcome after Intracerebral Hemorrhage

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Achint Patel ◽  
Sopan Lahewala ◽  
Neil Patel ◽  
Girish N Nadkarni ◽  
Grishma Dhaduk ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Hospital Mortality ◽  
Adverse Outcome ◽  
Adverse Outcomes ◽  
Categorical Variables ◽  
Do Not Resuscitate ◽  
Multilevel Regression ◽  
Co Morbidity ◽  
The Impact ◽  
Dnr Orders

Background: The impact of do-not-resuscitate (DNR) orders on outcomes has not been systematically evaluated in Intracerebral Hemorrhage (ICH). Hypothesis: We assessed the impact of DNR orders in ICH and its association to mortality/related adverse outcomes. Methods: We reviewed the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample(NIS) database of 2011 for ICH using ICD 9-CM codes(431).This represents 20% of all US hospital patients and weighted numbers represent national estimates. We defined patients’ DNR status with ICD code V49.86 and comorbid conditions by Deyo’s modification of Charlson’s Comorbidity Index (CCI). We only included adult patients in our analysis. Our primary outcomes of interest were in-hospital mortality and adverse outcome (composite of mortality & discharge other than home). We utilized chi-square test for univariable analysis for categorical variables and generated hierarchical multilevel regression models to determine independent predictors of mortality and adverse outcome. Results: We analyzed a total of 13440 pts (weighted n= 64617) with ICH of which 2029 (weighted n=9713) patients had DNR status. The proportions of mortality (56% vs. 19%, p<0.001) and adverse outcome(89% vs 70%) were higher in patients with DNR orders. Even after adjusting for confounders (demographics, Deyo’s modification of charlson’s co-morbidity index, admission type (elective vs emergent), hospital region, hospital teaching status, hospital ICH volume and primary payer), DNR status was associated with higher in hospital mortality (OR 6.98, 95% CI 6.58-7.41), p<0.001) and higher odds of adverse outcome (OR 3.98, 95% CI 3.64-4.34, p<0.001). Conclusion: DNR status in patients admitted with ICH appears to be a independent and significant predictor of substantially increased hospital mortality and adverse outcomes. The reasons for this are multifactorial and likely involve patient as well as systematic factors.Further studies including both quantitative/qualitative aspects are warranted to investigate these factors in detail.

scholarly journals Treatment Restrictions and the Risk of Death in Patients With Ischemic Stroke or Intracerebral Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (9) ◽  
pp. 2683-2689
Author(s):  
Hendrik Reinink ◽  
Burak Konya ◽  
Marjolein Geurts ◽  
L. Jaap Kappelle ◽  
H. Bart van der Worp
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Median Time ◽  
Cox Regression ◽  
University Hospital ◽  
Do Not Resuscitate ◽  
Risk Of Death ◽  
Increased Risk ◽  
Treatment Restrictions ◽  
Dnr Orders

Background and Purpose: Do-not-resuscitate (DNR) orders in the first 24 hours after intracerebral hemorrhage have been associated with an increased risk of early death. This relationship is less certain for ischemic stroke. We assessed the relation between treatment restrictions and mortality in patients with ischemic stroke and in patients with intracerebral hemorrhage. We focused on the timing of treatment restrictions after admission and the type of treatment restriction (DNR order versus more restrictive care). Methods: We retrospectively assessed demographic and clinical data, timing and type of treatment restrictions, and vital status at 3 months for 622 consecutive stroke patients primarily admitted to a Dutch university hospital. We used a Cox regression model, with adjustment for age, sex, comorbidities, and stroke type and severity. Results: Treatment restrictions were installed in 226 (36%) patients, more frequently after intracerebral hemorrhage (51%) than after ischemic stroke (32%). In 187 patients (83%), these were installed in the first 24 hours. Treatment restrictions installed within the first 24 hours after hospital admission and those installed later were independently associated with death at 90 days (adjusted hazard ratios, 5.41 [95% CI, 3.17–9.22] and 5.36 [95% CI, 2.20–13.05], respectively). Statistically significant associations were also found in patients with ischemic stroke and in patients with just an early DNR order. In those who died, the median time between a DNR order and death was 520 hours (interquartile range, 53–737). Conclusions: The strong relation between treatment restrictions (including DNR orders) and death and the long median time between a DNR order and death suggest that this relation may, in part, be causal, possibly due to an overall lack of aggressive care.

Abstract P454: Do Not Resuscitate Orders in Intracerebral Hemorrhage Patients. Impact on Mortality

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Mohammad Rauf A Chaudhry ◽  
Hussan Gill ◽  
Saqib Chaudhry ◽  
Baljinder Singh ◽  
Harathi Bandaru ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
The Self ◽  
Racial Groups ◽  
Do Not Resuscitate ◽  
Code Status ◽  
International Classification Of Disease ◽  
Discharge Outcomes ◽  
Racial Ethnic ◽  
Dnr Orders

Introduction/background: Do not resuscitate (DNR) orders have been associated with higher mortality in hospitalized patients which the question if they these patients are victims of the self-fulfilling prophecy; that the odds of their survival is made worse by withholding aggressive treatment. In addition, previous reports show that racial and ethnic minorities tend to opt for more aggressive and lifesaving procedures as compared to Whites. Methods: We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all intracerebral hemorrhage (ICH) patients. DNR code status was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, length of stay) were compared between the two groups. DNR code status was compared between different racial groups. Results: Of the 884379 patients with ICH, 81968 (9.26%%) had DNR order. ICH patients with DNR order had higher proportion of females (55.1% versus 49.1%, P <.0001) and were older (74.2 years versus 66 years, P <.0001) compared to ICH patients without DNR. The in-hospital mortality was also higher (53.4% versus 23.3%, p≤.0001) among patients with DNR both univariate and multivariate analysis (OR = 3.24 (3.07 -3.41), p<.0001) after adjusting for potential confounders. Whites have a higher rate (11.5% versus 8.08%) of DNR order as compared to other racial/ethnic groups Conclusions: While there may be other explanations at play, the higher mortality and shorter LOS suggest that early DNR orders do lead to the self-fulfilling prophecy. The lower proportion of DNR orders among minorities suggest a sociocultural aspect in accepting the concept of DNR. These two facts raise concerns about what the real vs perceived meaning of DNR orders.

Do-Not-Resuscitate (DNR) Orders in Patients with Intracerebral Hemorrhage

2013 ◽  
Vol 9 (1) ◽  
pp. 53-58 ◽  
Author(s):  
Katri Silvennoinen ◽  
Atte Meretoja ◽  
Daniel Strbian ◽  
Jukka Putaala ◽  
Markku Kaste ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Do Not Resuscitate ◽  
Dnr Orders

scholarly journals The Decision not to Resuscitate Order for Children and Related Ethical Issues from Students’ Perspective

2020 ◽  
Author(s):  
sawsan abuhammad ◽  
Suhiab Mufleh ◽  
Karem H Alzoubi
Keyword(s):  
Nursing Students ◽  
Undergraduate Students ◽  
Ethical Issues ◽  
Terminally Ill ◽  
P Value ◽  
Do Not Resuscitate ◽  
Correlational Design ◽  
Significant Difference ◽  
Excellent Care ◽  
Dnr Orders

Abstract Background : Nurses and PharmD have communicated the for elaborate and properly documented DNR orders for terminally ill children and informed child with terminally ill diseases and relatives to offer excellent care attention, such as more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary CPR This research aimed to survey attitudes of nursing and PharmD (PharmD) undergraduate students about the “do not resuscitate” order for children with terminally ill diseases.Method: Across-sectional correlational design was used. More than 400 nursing and PharmD students were recruited in this study. All nursing and doctors of pharmacy undergraduate students were E-mailed information regarding the study, including the web survey link.Results: Approximately 60% of the nursing and PharmD students would disclose the need for the do not resuscitate order for children with terminally ill diseases. The results showed that there was a significant difference in perception toward DNR order between nursing and PharmD. PharmD students had more positive attitude toward DNR than nursing students. Conclusion: The results of this study showed that all demographic variables not associated with the perception toward DNR orders (p value > 0.05). This study shows that Jordanian nursing and PharmD students are willing to learn more about different aspects of DNR orders for terminally ill children and analyzing their responses to many items showed their misconception about DNR orders for terminally ill children.

Hematoma Hounsfield units and expansion of intracerebral hemorrhage: A potential marker of hemostatic clot contraction

2020 ◽  
pp. 174749301989570 ◽  
Author(s):  
Han-Gil Jeong ◽  
Jae Seung Bang ◽  
Beom Joon Kim ◽  
Hee-Joon Bae ◽  
Moon-Ku Han
Keyword(s):  
Computed Tomography ◽  
Logistic Regression ◽  
Intracerebral Hemorrhage ◽  
Hematoma Expansion ◽  
P Value ◽  
Discrimination Power ◽  
Multivariable Logistic Regression ◽  
C Statistic ◽  
Potential Marker ◽  
Clot Contraction

Background Clot contraction reinforces hemostasis by providing an impermeable barrier and contractile force. Since computed tomography attenuation of intracerebral hemorrhage is largely determined by the density of red blood cells, clot contraction can be reflected in an increase of Hounsfield unit (HU) of hematoma. Aims We hypothesized that hematoma expansion is inversely associated with mean HU of intracerebral hemorrhage at presentation. Methods Eighty-nine consecutive spontaneous intracerebral hemorrhage patients with onset to first computed tomography within 24 h were included. Hematomas were segmented using semiautomated planimetry to measure the volume and mean HU. Hematoma expansion was defined as an increase in hematoma volume by over 33% or 6 mL. Multivariable logistic regression was performed for hematoma expansion. The discrimination power of mean HU for hematoma expansion was assessed using C-statistic. Results The computed tomography attenuation of hematoma at presentation was 57.5 ± 3.3 HU and the volume was 16.9 ± 23.2 mL. Hematoma expansion occurred in 37.1% of patients. The computed tomography attenuation of hematoma was lower in patients with hematoma expansion than with no expansion (55.7 ± 2.9 HU vs. 58.6 ± 3.1 HU, p-value < 0.01). Multivariable logistic regression revealed that the mean HU of hematoma was inversely associated with hematoma expansion (adjusted odds ratio, 0.64; 95% confidence interval, 0.51–0.80). The C-statistic of the model with four known predictors increased from 0.66 to 0.84 after incorporating mean HU (p-value < 0.01). Conclusions Intracerebral hemorrhage with lower mean HU of hematoma at presentation is more likely to undergo hematoma expansion. This finding suggests the potential presence of clot contraction process that reinforces hemostasis in intracerebral hemorrhage.

Abstract T P340: Delays in Seeking Medical Attention in Intracerebral Hemorrhage

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Fernando D Testai ◽  
Carl D Langefeld ◽  
Faisal Mukarram ◽  
Norma K Castillo ◽  
Maureen Hillmann ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Linear Models ◽  
Private Insurance ◽  
Univariate Analysis ◽  
Multivariate Model ◽  
Medical Attention ◽  
P Value ◽  
Insurance Status ◽  
Presenting Symptoms ◽  
The Impact

Background: Intracerebral hemorrhage (ICH) is associated with early neurological deterioration and death. Prior studies showed that delays in seeking medical attention may occur among minorities. In this study we investigated the factors affecting time from symptom onset to ER arrival (TOA) in a race/ethnic enriched population. Methods: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) is a prospective study of spontaneous ICH. Baseline characteristics, presenting symptoms, first contact (911 vs. ER vs. primary physician), ICH volume, location and intraventricular extension, insurance status, GCS at presentation, and TOA were collected. Data was analyzed using generalized linear models and Spearman’s rank correlations. TOA was natural log transformed and a multivariate model was developed using backward elimination (P-value=0.05). Results: A total of 1158 subjects were enrolled; 28 were excluded due to lack of TOA. Of the 1,030 included 59% were men with 24% whites, 41% blacks, and 35% Hispanics. Mean age was 61±15 years, mean Glasgow Coma Scale (GCS) at presentation was 12.4±3.7 (median=15), and median TOA was 431 min (interquartile range 106-820). Location of ICH was 56% deep, 28% lobar, 8% cerebellum, and 5% brainstem. Approximately 29% of subjects had no medical insurance, 36% had medicare, 18% medicaid, 36% private insurance, and 1% VA insurance. In univariate analysis women, use of 911, EMS run, different presenting symptoms, lobar and deep location, and low GCS were associated with shorter TOA. In multivariate model only women (p=0.05), GCS (p=0.04), use of 911 (p<0.001), EMS run (p<0.001), and weakness and dysarthria as presenting symptoms remained significant. Ethnicity was not a significant predictor (p=0.79). These variables explain 23.3% of the variation in TOA. Conclusion: Ethnicity and insurance status did not affect time to presentation. Women, use of 911, EMS run, weakness and lower GCS were associated with shorter TOA in ICH. Increased education in target populations with higher incidence of ICH such as minorities on stroke signs/symptoms and use of 911 may expedite access to medical care. Further studies are needed to determine the impact of TOA on outcome.

Orders Not to Resuscitate: The Sharon Siebert Case

1981 ◽  
Vol 2 (5) ◽  
pp. 3-7
Author(s):  
George J. Annas
Keyword(s):  
Do Not Resuscitate ◽  
Lower Court ◽  
Legal Standard ◽  
Dnr Orders

In a previous column I discussed the testimony of a number of nurses in the case of Ms. Sharon Siebert. That case was decided by a lower court on February 13, 1981, and this column discusses Judge Lindsay G. Arthur's opinion. Jane Hoyt, a friend, not a relative, of Ms. Siebert, brought suit to enjoin an order not to resuscitate that had been written on Ms. Siebert. The case raised a number of important issues, including whether the court would allow a suit brought by someone in Ms. Hoyt's position vis-à-vis the patient, and if it did, what legal standard the court might require in the writing of Do Not Resuscitate (DNR) orders.

scholarly journals Interatrial block is related to atrial dysfunction in hypertensive subjects

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
L Tirapu Sola ◽  
F Loncaric ◽  
M Mimbrero ◽  
LG Mendieta ◽  
L Nunno ◽  
...  
Keyword(s):  
Global Longitudinal Strain ◽  
Female Gender ◽  
Left Ventricular ◽  
P Wave ◽  
P Value ◽  
Atrial Remodeling ◽  
Maximal Volume ◽  
Surface Ecg ◽  
Interatrial Block ◽  
And Function

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): La Marató TV3 Background Interatrial block (IAB), a delay of conduction of the sinus stimulus from right to left atria (LA), is defined as surface ECG P-wave duration ≥120 ms. Arterial hypertension (AH) and IAB have been related to development of atrial fibrillation. Aim To investigate the IAB prevalence in a cohort of AH patients and relate it to LA function. Methods 162 patients with well-regulated AT were included. 12-lead ECG were performed and analysed with a digital caliper. 2D and 3D echocardiography were performed, and LA function assessed with speckle-tracking deformation imaging.  Results The median age was 56 ± 6 years, 54% were males. Average duration of AH was 10 ± 6 years. IAB was seen in 25% of AH patients.  The comparison between groups is shown in Table 1. There were no differences in demographic characteristics,  QRS complex duration (p = 0.179) or left ventricular (LV) size and function between subgroups. LA was enlarged in IAB patients, which was coupled with impairment of the LA reservoir strain.  Conclusion Our results show considerable prevalence of IAB in AH patients. The demonstrated LA enlargement and function impairment is not associated with LV dysfunction, therefore suggesting an independent role of IAB in atrial remodeling. Table 1 Interatrial block P value Yes (n= 40) No (n= 142) Age 59 (54-62) 57 (53-61) 0.157 Female gender 16 (40%) 58 (48%) 0.467 Duration of Hypertension (years) 10 (6-12) 8 (5-15) 0.421 Systolic blood pressure (mmHg) 136 (125-150) 136 (127-147) 0.799 Diabetes 3 (8%) 16 (13%) 0.410 LVEDV (mL) 73 (63-91) 71 (57-87) 0.424 E/A 0.98 (0.84-1.25) 0.94 (0.79-1.11) 0.230 E/e’ 7.0 (4.9-8.9) 6.6 (5.2-8.4) 0.779 LVEF (%) 63 ± 7 64 ± 6 0.864 LV global longitudinal strain (%) 21.22 ± 2.63 21.19 ± 2.30 0.932 3D LA maximal volume (mL/m2) 36 (30-39) 30 (26-37) 0.028 3D LA minimal volume (mL/m2) 16 (12-18) 14 (11-17) 0.050 LA reservoir strain (%) 27.64 (24.90-31.23) 29.55 (26.17-32.81) 0.032 LA conduit strain (%) 13.91 (10.71-15.47) 14.37 (11.75-16.72) 0.192 LA contractile strain (%) 14.46 (11.86-16.59) 15.52 (13.66-16.96) 0.079 LVEDV Left Ventricular End Dyastolic Volume

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