Abstract T MP73: Effect of Hospital Factors on Individual-Level Early Do-Not-Resuscitate Orders in Ischemic Stroke

Abstract

Background: Race-ethnic (R/E) minorities are less likely to have Do-Not-Resuscitate (DNR) orders than non-Hispanic whites. Since race and ethnicity cluster by hospital, institutional factors may contribute to this variability in DNR orders. We investigated the influence of hospital-level proportion of R/E minorities on R/E differences in individual-level DNR decisions. Methods: Cases of ischemic stroke were identified from the California State Inpatient Database (age >=50, 2005-2011, ICD-9 codes 433.x1, 434.x1, 436 in primary position). Hospitals were classified by the proportion of R/E minority (Black or Hispanic) patients seen at each institution (reported as quartiles). Individual-level early DNR orders (within 24 hours) were reported by individual-level race-ethnicity (White, Asian, Hispanic, or Black), stratified by hospital-level proportion of R/E minority (Black or Hispanic) patients using multilevel logistic regression with a random hospital intercept. Results: A total of 259,953 cases of ischemic stroke across 370 hospitals were included (Mean age 74, Female 53%, White 59%, Black 8.8%, Hispanic 17%, Asian 8.9%, Others 6.0%). There was variability in the proportion of R/E minority patients seen at the hospital level (Black: range 0-82%, median 2.3%; Hispanic: range 0-96%, median 12.2%). Increasing hospital-level proportion of minority patients seen was associated with less use of DNR orders across all R/E groups. Similar effects were seen when stratified by hospital-level quartile of Black (Figure “A”) or Hispanic (Figure “B”) patients (p<0.001 for both). White patients with ischemic stroke admitted to hospitals that cared for more minority patients used early DNR orders at a frequency similar to R/E minorities. Conclusions: The probability of an early DNR order after ischemic stroke is due not only to different treatment patterns across R/E groups, but also to differential treatment patterns at hospitals that care for more R/E minorities.