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. 2017 Jun;7(3):194-204.
doi: 10.1212/CPJ.0000000000000358.

Early transition to comfort measures only in acute stroke patients: Analysis from the Get With The Guidelines-Stroke registry

Shyam Prabhakaran  1 , Margueritte Cox  1 , Barbara Lytle  1 , Phillip J Schulte  1 , Ying Xian  1 , Darin Zahuranec  1 , Eric E Smith  1 , Mathew Reeves  1 , Gregg C Fonarow  1 , Lee H Schwamm  1
Affiliations

Early transition to comfort measures only in acute stroke patients: Analysis from the Get With The Guidelines-Stroke registry

Shyam Prabhakaran et al. Neurol Clin Pract. 2017 Jun.

Abstract

Background: Death after acute stroke often occurs after forgoing life-sustaining interventions. We sought to determine the patient and hospital characteristics associated with an early decision to transition to comfort measures only (CMO) after ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in the Get With The Guidelines-Stroke registry.

Methods: We identified patients with IS, ICH, or SAH between November 2009 and September 2013 who met study criteria. Early CMO was defined as the withdrawal of life-sustaining treatments and interventions by hospital day 0 or 1. Using multivariable logistic regression, we identified patient and hospital factors associated with an early (by hospital day 0 or 1) CMO order.

Results: Among 963,525 patients from 1,675 hospitals, 54,794 (5.6%) had an early CMO order (IS: 3.0%; ICH: 19.4%; SAH: 13.1%). Early CMO use varied widely by hospital (range 0.6%-37.6% overall) and declined over time (from 6.1% in 2009 to 5.4% in 2013; p < 0.001). In multivariable analysis, older age, female sex, white race, Medicaid and self-pay/no insurance, arrival by ambulance, arrival off-hours, baseline nonambulatory status, and stroke type were independently associated with early CMO use (vs no early CMO). The correlation between hospital-level risk-adjusted mortality and the use of early CMO was stronger for SAH (r = 0.52) and ICH (r = 0.50) than AIS (r = 0.15) patients.

Conclusions: Early CMO was utilized in about 5% of stroke patients, being more common in ICH and SAH than IS. Early CMO use varies widely between hospitals and is influenced by patient and hospital characteristics.

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Figures

Figure 1
Figure 1. Flowchart of study cohort assembly
AHA = American Heart Association; CMO = comfort measures only; GWTG = Get With The Guidelines; ND = not documented; UTD = unable to determine.
Figure 2
Figure 2. Estimated distribution of hospital-specific early comfort measures only (CMO) rates in stroke patients
Hospital-level variation in early CMO use in stroke patients: (solid line) all stroke patients, (dashed line) patients with acute ischemic stroke (AIS), (dotted line) patients with subarachnoid hemorrhage (SAH), and (dash and dotted line) patients with intracerebral hemorrhage (ICH). The interclass correlation coefficient was 0.107 overall, 0.116 in AIS patients, 0.110 in SAH patients, and 0.115 in ICH patients.
Figure 3
Figure 3. Risk-adjusted mortality vs risk-adjusted early comfort measures only (CMO)
Risk-adjusted mortality vs risk-adjusted early CMO use (A) overall, (B) in patients with acute ischemic stroke, (C) in patients with intracerebral hemorrhage, and (D) in patients with subarachnoid hemorrhage.
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