Do minorities survive hospitalization better than others?

A Do Not Resuscitate (DNR) order can certainly guide family members who are faced with difficult end-of-life decisions and might have simplified the plight of Terry Schiavo. Increasing usage of these orders can factor into the interpretation of clinical observations. While two recent studies showed lower in-hospital mortality for African-Americans than for non-Hispanic whites, in a study published in the current issue of The American Journal of Medicine, researchers from the University of California, San Francisco investigated the incidence of DNR orders in a large population of hospital patients. When sex and ethnicity differences in the use of DNR orders were taken into account, the apparent mortality advantage for minorities disappeared.

Over 300,000 patients admitted to non-federal California hospitals in 1999 were part of this study. Over 25,000 of these patients had DNR orders. Women were 19% more likely to have DNR orders than men and non-Hispanic whites were 43% more likely to have DNR orders than other ethnicities. Those with a DNR were more likely to die during their hospital stay.

Writing in the article, S. Claiborne Johnston, MD, PhD, writes, "Non-Whites were less likely to die in the hospital in an analysis ignoring DNR status, but this apparent mortality benefit disappeared after adjustment for DNR status. Thus, higher rates of DNR orders in Whites may create the appearance of a survival advantage for other ethnicities, and unmeasured differences in use of DNR orders may mask ethnic and sex disparities. In addition, odds of in-hospital mortality tended to be lower for women, and the survival advantage for women was even greater after DNR status was included in the models. Failure to capture DNR in the model could misrepresent the component of outcome that is due to disparities in the delivery of medical care. Furthermore, DNR may be a confounder in other studies of risk factors for mortality."

The study is reported in "Adjustment for Do-Not-Resuscitate Orders Reverses the Apparent In-Hospital Mortality Advantage for Minorities" by Naomi Bardach, MD, Shoujun Zhao, MD, PhD, Steven Pantilat, MD, S. Claiborne Johnston, MD, PhD. This article appears in The American Journal of Medicine, Volume 118, Number 4, published by Elsevier.

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