Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock*.
Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock*.
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DOI：
10.1097/ccm.0000000000000403
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发表时间：
2014-09
影响因子：
8.8
通讯作者：
Walkey AJ
中科院分区：
文献类型：
--
作者：
Bradford MA;Lindenauer PK;Wiener RS;Walkey AJ
评估在重症监护观察性比较有效性研究中纳入不复苏(DNR)状态的重要性。回顾分析参与2007加州州立住院病人数据库的所有加州医院，该数据库提供入院后24小时内的DNR状态。入院时出现感染性休克。无我们调查了感染性休克患者早期DNR状态与住院死亡率的关系。我们还检验了DNR状态与活化蛋白C治疗和死亡率之间关系的混淆强度，这与观察性研究和随机研究之间的相互矛盾的结果相关联。我们确定了24,408名感染性休克患者；19.6%的患者有DNR顺序。与没有DNR顺序的患者相比，有DNR顺序的患者更有可能年龄更大(75±14岁比67±16岁)，白人(62%比53%)，有更多的急性器官衰竭(1.44±1.15比1.38±1.15)，但住院干预(1.0±1.0比1.4±1.1)更少。在有46个协变量的模型中加入DNR状态改善了死亡率辨别力(c-统计量0.73至0.76，p<；0.001)。在评估活化蛋白C和死亡率之间关系的多变量模型中加入DNR状态，导致活化蛋白C效应估计向零偏移8%[优势比0.78；(95%可信区间0.61-0.99)，p=0.04至0.85(0.67-1.08)，p=0.19]。在感染性休克的患者中，DNR状态是一个强烈的混杂因素，可能会导致过去对活性蛋白C的观察性研究和随机研究之间的差异。将早期DNR状态纳入更多的管理数据库可能会改进观察比较有效性方法学。
To assess the importance of including Do Not Resuscitate (DNR) status in critical care observational comparative effectiveness research. Retrospective analysis All California hospitals participating in the 2007 California State Inpatient Database – which provides DNR status within the first 24 hours of admission. Septic shock present on admission. None We investigated the association of early DNR status with in-hospital mortality among patients with septic shock. We also examined the strength of confounding of DNR status on the association between activated protein C therapy and mortality, an association with conflicting results between observational and randomized studies. We identified 24,408 patients with septic shock; 19.6% had a DNR order. Compared to patients without a DNR order, those with a DNR order were significantly more likely to be older (75±14 vs. 67±16 years), white race (62% vs. 53%), with more acute organ failures (1.44±1.15 vs. 1.38±1.15), but fewer in-patient interventions (1.0±1.0 vs. 1.4±1.1). Adding DNR status to a model with 46 covariates improved mortality discrimination (c-statistic 0.73 to 0.76, p<0.001). Addition of DNR status to a multivariable model assessing the association between activated protein C and mortality resulted in an 8% shift in the activated protein C effect estimate towards the null [odds ratio 0.78; (95% CI 0.61–0.99), p=0.04 to 0.85 (0.67–1.08), p=0.19]. Among patients with septic shock, DNR status acts as a strong confounder that may inform past discrepancies between observational and randomized studies of activated protein C. Inclusion of early DNR status into more administrative databases may improve observational comparative effectiveness methodology.