Laura B. Shepardson

INCREASED RISK OF DEATH IN PATIENTS WITH DO-NOT-RESUSCITATE ORDERS

BACKGROUND Whereas studies have shown higher mortality rates in patients with do-not-resuscitate (DNR) orders, most have not accounted for confounding factors related to the use of DNR orders and/or factors related to the risk of death. OBJECTIVE To determine the relationship between the use of DNR orders and in-hospital mortality, adjusting for severity of illness and other covariates. DESIGN Retrospective cohort study. PATIENTS There were 13,337 consecutive stroke admissions to 30 hospitals in 1991 to 1994. MEASURES To decrease selection bias, propensity scores reflecting the likelihood of a DNR order were developed. Scores were based on nine demographic and clinical variables independently related to use of DNR orders. The odds of death in patients with DNR orders were then determined using logistic regression, adjustment for propensity scores, severity of illness, and other factors. RESULTS DNR orders were used in 22% (n = 2,898) of patients. In analyses examining DNR orders written at any time during hospitalization, unadjusted in-hospital mortality rates were higher in patients with DNR orders than in patients without orders (40% vs. 2%, P<0.001); the adjusted odds of death was 33.9 (95% CI, 27.4-42.0). The adjusted odds of death remained higher in analyses that only considered orders written during the first 2 days (OR 3.7; 95% CI, 3.2-4.4) or the first day (OR 2.4; 95% CI, 2.0-2.9). In stratified analyses, adjusted odds of death tended to be higher in patients with lower propensity scores. CONCLUSION The risk of death was substantially higher in patients with DNR orders after adjusting for propensity scores and other covariates. Whereas the increased risk may reflect patient preferences for less intensive care or unmeasured prognostic factors, the current findings highlight the need for more direct evaluations of the quality and appropriateness of care of patients with DNR orders.

Are readmissions to the intensive care unit a useful measure of hospital performance

BACKGROUND Although patients readmitted to intensive care units (ICUs) typically have poor outcomes, ICU readmission rates have not been studied as a measure of hospital performance. OBJECTIVES To determine variation in ICU readmission rates across hospitals and associations of readmission rates with other ICU-based measures of hospital performance. RESEARCH DESIGN Observational cohort study. SUBJECTS One hundred three thousand nine hundred eighty four consecutive ICU patients who were admitted to twenty eight hospitals who were then transferred to a hospital ward in those 28 hospitals. MEASURES Predicted risk of in-hospital death and ICU length of stay (LOS) were determined by a validated method based on age, ICU admission source, diagnosis, comorbidity, and physiologic abnormalities. Severity-adjusted mortality rates, LOS, and readmission rates were determined for each hospital. RESULTS One or more ICU readmissions occurred in 5.8% patients who were initially classified as postoperative and in 6.4% patients who were initially classified as nonoperative. In-hospital mortality rate was 24.7% in patients who were readmitted as compared with 4.0% in other patients (P < 0.001). After adjusting for predicted risk of death, the odds of death remained 7.5 times higher (OR 7.5, 95% CI, 6.8-8.3). Readmitted patients also had longer (P < 0.001) ICU LOS (5.2 vs. 3.7 days) and hospital LOS (29.3 vs. 11.7 days). Severity-adjusted readmission rates varied across hospitals from 4.2% to 7.6%. Readmission rates were not correlated with severity-adjusted hospital mortality, ICU LOS, or hospital LOS. CONCLUSIONS ICU patients who were subsequently readmitted have a higher risk of death and longer LOS after adjusting for severity of illness. However, readmission rates were not associated with severity-adjusted mortality or LOS. Those data indicate that ICU readmission may capture other aspects of hospital performance and may be complementary to these measures.

Racial Variation in the Use of Do-Not-Resuscitate Orders

OBJECTIVE: To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample.MEASUREMENTS: Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82–0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates.MAIN RESULTS: In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p<.001). Rates of orders were also lower (p<.001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower (p<.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days.CONCLUSIONS: The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.

Pediatric bone marrow cellularity: are we expecting too much?

Purpose: Accurate assessment of marrow cellularity is necessary for establishing diagnoses and monitoring the effects of treatment in a large number of malignant and nonmalignant pediatric illnesses, and for evaluating sibling donors for transplantation. However, normal values for age-related bone marrow cellularity in pediatric patients have not been well established. This study was designed to better define pediatric normal values for bone marrow cellularity. Patients and Methods: A retrospective review of 448 bone marrow core biopsy or clot specimens, including 45 samples from healthy donors, were taken from the posterior iliac crest of patients aged from younger than 1 to 18 years (55% male). All samples were collected and fixed in a standardized fashion. Patients with hematopoietic malignancies and other systemic conditions known to impact marrow cellularity were excluded. Results: The mean cellularity of the entire sample was 65.4%. Cellularity was similar in boys and girls, but varied (p < 0.001) with age. Cellularity was highest in patients younger than 2 years (79.8%), and declined in patients 2 to 4 years old (68.6%) and 5 to 9 years old (59.1%). Cellularity remained stable in older patients (60.1% and 61.1%. respectively, in patients 10 to 14 and 15 to 18 years of age). Adjusting for age and gender, mean cellularity was similar in patients with an underlying nonhematologic malignancy compared to healthy donors but was roughly 6% higher in patients with hematopoietic disorders. Conclusions: This study demonstrates that average cellularity during the first two decades of life, using current techniques of marrow collection and standardized analysis, is lower than previously estimated. In addition, cellularity declined with age until the age of 5 years, but was similar thereafter. After adjusting for age. differences according to diagnosis were relatively small.