Mortality-based quality measures that do not account for do-not-resuscitate orders paint a skewed picture of hospital performance, said authors of a multicenter retrospective cohort study.
“Our findings suggest that current methods of comparing hospitals, which do not account for patient DNR status, penalize potentially high-quality hospitals [that admit] a larger proportion of patients who had chosen to forgo resuscitation,” Dr. Allan J. Walkey of Boston University, and his associates wrote online Dec. 14 in JAMA Internal Medicine. Accounting for DNR status when evaluating mortality outcomes “may substantially affect publicly reportable hospital rankings and hospital reimbursements,” the researchers added.
Dr. Allan J. Walkey
Early DNR orders typically reflect patient-specific variables, such as baseline comorbidities and attitudes about end-of-life care, the researchers noted. “Despite the potential for hospital variation in DNR orders to influence patients’ end-of-life experiences and outcomes, DNR status is generally unreported by hospitals and unaccounted for in hospital outcome measures,” they added. Their population-based cohort study assessed DNR status and mortality for more than 90,000 pneumonia cases at 303 hospitals in California during 2011 (JAMA Intern Med. 2015 Dec. 14. doi: 10.1001/jamainternmed.2015.6324).
The lower and upper quartiles for DNR rates were about 9% and 22%, said the researchers. Without accounting for these differences, hospitals in the highest quartile had significantly greater patient mortality than did those in the lowest quartile (adjusted odds ratio, 1.17; 95% confidence interval, 1.04-1.32), corresponding to worse mortality rankings. But this trend actually reversed after the investigators accounted for DNR rates (adjusted OR, 0.79; 95% CI, 0.70-0.89), as did the link between hospital mortality rankings and DNR rates.
Only about half of hospitals that were low-performing outliers without accounting for DNR status remained outliers after adjustment, the researchers noted. And although DNR rates did not significantly correlate with composite quality measures of pneumonia care, they were positively linked to patient satisfaction scores (P less than .001). Based on the findings, “stakeholders should seek to improve methods to standardize and report DNR status in hospital discharge records,” they concluded.
The study was funded by the National Institutes of Health, the National Heart, Lung, and Blood Institute of the NIH, the Agency for Healthcare Research and Quality, the Edith Nourse Rogers Memorial Veterans Affairs Hospital, and Boston University. The researchers had no disclosures.