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

Bailoor, Kunal; Shafie-Khorassani, Fatema; Lank, Rebecca J; Case, Erin; Garcia, Nelda; Lisabeth, Lynda D.; Sánchez, Brisa N.; Kim, Sehee; Morgenstern, Lewis B.; Zahuranec, Darin B.

doi:10.1161/strokeaha.118.024460

Cited by 13 publications

(6 citation statements)

References 37 publications

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“…However, the direction of the effect remained in favor of better outcomes among MA surrogates, contrary to our original hypothesis. Surrogate decision-making about life-sustaining treatment after stroke is common 1,5 with potential implications for life or death decisions for the patient 17 and potential long-term adverse impact on surrogates 3 and yet been largely understudied in the setting of stroke. These findings from a community-based study examining stroke surrogate decision-making and surrogate-reported outcomes may help to draw attention to the importance of studying the effects of stroke on the entire family.…”

Section: Discussionmentioning

confidence: 99%

“…Studies to date have also shown differences in the frequency of decisions to limit life-sustaining treatments by race and ethnicity. [4][5][6] We have shown that Mexican American (MA) patients are less likely than non-Hispanic White (NHW) patients to have early do-not-resuscitate (DNR) orders after stroke. 5 Despite longstanding documentation of differences in treatment patterns by race and ethnicity, reasons underlying these differences remain elusive.…”

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confidence: 99%

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Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project

Zahuranec,

Ortiz,

Lank

et al. 2024

Stroke

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Background: Patients with severe stroke often rely on surrogate decision-makers for life-sustaining treatment decisions. We investigated ethnic differences between Mexican Americans (MAs) and non-Hispanic White (NHW) individuals in surrogate reports of physician quality of communication and shared decision-making from the OASIS study (Outcomes Among Surrogate Decision Makers in Stroke) project. Methods: Patients had ischemic stroke or intracerebral hemorrhage in Nueces County, TX. Surrogates self-identified as being involved in decisions about do-not-resuscitate orders, brain surgery, ventilator, feeding tube, or hospice/comfort care. Surrogate reports of physician quality of communication (scale score, range from 0 to 10) and shared decision-making (CollaboRATE scale score, binary score 1 versus 0) were compared by ethnicity with linear or logistic regression using generalized estimating equations, adjusted for prespecified demographics, clinical factors, and confounders. Results: Between April 2016 and September 2020, 320 surrogates for 257 patients with stroke enrolled (MA, 158; NHW, 85; and other, 14). Overall quality of communication score was better among surrogates of MA patients than NHW individuals after adjustment for demographics, stroke severity, and patient survival though the ethnic difference was attenuated (β, 0.47 [95% CI, −0.17 to 1.12]; P =0.15) after adjustment for trust in the medical profession and frequency of personal prayer. High CollaboRATE scale scores were more common among surrogates of MA patients than NHW individuals (unadjusted odds ratio, 1.75 [95% CI, 1.04–2.95]). This association persisted after adjustment for demographic and clinical factors though there was an interaction between patient age and ethnicity ( P =0.04), suggesting that this difference was primarily in older patients. Conclusions: Surrogate decision-makers of MA patients generally reported better outcomes on validated measures of quality of communication and shared decision-making than NHW individuals. Further study of outcomes among diverse populations of stroke surrogate decision-makers may help to identify sources of strength and resiliency that may be broadly applicable.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project

Zahuranec,

Ortiz,

Lank

et al. 2024

Stroke

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“…An NIS study of individuals with hemorrhagic strokes showed that White patients are more likely to receive DNR or palliative orders 30 . A study in 2006-2014 showed that DNR orders in AIS were less likely to be given to Mexican Americans and Black individuals within 24 hours, but no difference was found afterwards 31 . Another study reported lower utilization of palliative care in 2007-2011 in non-White minority patients in all hospital strata by the proportion of the non-White patients served, as well as in all race/ethnicities in hospitals predominantly serving the non-White patients 32 .…”

Section: Discussionmentioning

confidence: 99%

Effects of System-Level Factors on Race/Ethnic Differences in In-Hospital Mortality after Acute Ischemic Stroke

Sun,

Markovic,

Ibish

et al. 2023

Preprint

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Introduction: Stroke mortality declined, with differential changes by race; stroke is now the 5th leading cause of death overall, but 2nd leading cause of death in Black individuals. Little is known about recent race/ethnic and sex trends in in-hospital mortality after acute ischemic stroke(AIS) and whether system-level factors contribute to possible differences. Methods: Using the National Inpatient Sample, adults with a primary diagnosis of AIS from 2006 to 2017 (n=643,912) were identified. We assessed in-hospital mortality by race/ethnicity, sex, and age. Hospitals were categorized by proportion of non-White patients served: <25% (?predominantly White patients?), 25-50% (?mixed race/ethnicity profile?), and ?50% (?predominantly non-White patients?). Using survey-adjusted logistic regression, the association between race/ethnicity and odds of mortality was assessed, adjusting for key sociodemographic, clinical, and hospital characteristics. Results: Overall, mortality decreased from 5.0% in 2006 to 2.9% in 2017 (p<0.001). Comparing 2012-2017 to 2006-2011, there was a 68% reduction in mortality odds after adjusting for covariates, most prominent in White individuals (69%) and smallest in Black individuals (57%). Compared to White patients, Black and Hispanic patients had lower odds of mortality (adjusted odds ratio(aOR) 0.82, 95%CI 0.78-0.87 and aOR 0.93, 0.87-1.00), primarily driven by those >65 years (age x ethnicity interaction p<0.0001). Compared to White men, Black, Hispanic, and API men, and Black women had lower aOR of mortality. The differences in mortality between White and non-White patients were most pronounced in hospitals predominantly serving White patients (aOR 0.80, 0.74-0.87) compared to mixed hospitals (aOR 0.85, 0.79-0.91) and predominantly non-White hospitals (aOR 0.88, 0.81-0.95; interaction effect: p=0.005). Discussion: AIS mortality decreased dramatically in recent years in all race/ethnic subgroups. Overall, non-White AIS patients had lower mortality than their White counterparts, a difference that was most striking in hospitals predominantly serving White patients. Further study is needed to understand these differences and to what extent biological, sociocultural, and system-level factors play a role.

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“…12 Previous research concerning DNR orders in the inpatient setting suggests that racial and ethnic differences have not changed over time. 13,14 However, there is increasing interest in understanding variation in medical decision-making by race and ethnicity. Cardiopulmonary resuscitation (CPR) preferences captured in POLST over time have not been explored.…”

Section: Introductionmentioning

confidence: 99%

“…But, fewer Black and Hispanic nursing home residents, compared to White residents, have POLST forms containing DNR orders 12 . Previous research concerning DNR orders in the inpatient setting suggests that racial and ethnic differences have not changed over time 13,14 . However, there is increasing interest in understanding variation in medical decision‐making by race and ethnicity.…”

Section: Introductionmentioning

confidence: 99%

Changes over time in POLST use and content by race and ethnicity among California nursing home residents

Zingmond

Powell

Jennings

et al. 2023

J American Geriatrics Society

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BackgroundPhysician Orders for Life‐Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity.MethodsCalifornia requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content—orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned.ResultsPOLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two‐thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups.ConclusionsRacial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative.

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

Cited by 13 publications

References 37 publications

Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project

Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project

Effects of System-Level Factors on Race/Ethnic Differences in In-Hospital Mortality after Acute Ischemic Stroke

Changes over time in POLST use and content by race and ethnicity among California nursing home residents

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