0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Association of Do-Not-Resuscitate Orders and Hospital Mortality Rate Among Patients With Pneumonia

Allan J. Walkey, MD, MSc1; Janice Weinberg, ScD2; Renda Soylemez Wiener, MD, MPH1,3; Colin R. Cooke, MD, MSc, MS4,5; Peter K. Lindenauer, MD, MSc6,7
[+] Author Affiliations
1The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts
2Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
3Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
4Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
5Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
6Center for Quality of Care Research, Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts
7Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
JAMA Intern Med. 2016;176(1):97-104. doi:10.1001/jamainternmed.2015.6324.
Text Size: A A A
Published online

Importance  Hospital quality measures that do not account for patient do-not-resuscitate (DNR) status may penalize hospitals admitting a greater proportion of patients with limits on life-sustaining treatments.

Objective  To evaluate the effect of analytic approaches accounting for DNR status on risk-adjusted hospital mortality rates and performance rankings.

Design, Setting, and Participants  A retrospective, population-based cohort study was conducted among adults hospitalized with pneumonia in 303 California hospitals between January 1 and December 31, 2011. We used hierarchical logistic regression to determine associations between patient DNR status, hospital-level DNR rates, and mortality measures. Changes in hospital risk-adjusted mortality rates after accounting for patient DNR status and interhospital variation in the association between DNR status and mortality were examined. Data analysis was conducted from January 16 to September 16, 2015.

Exposures  Early DNR status (within 24 hours of admission).

Main Outcomes and Measures  In-hospital mortality, determined using hierarchical logistic regression.

Results  A total of 90 644 pneumonia cases (5.4% of admissions) were identified among the 303 California hospitals evaluated during 2011; mean (SD) age of the patients was 72.5 (13.7) years, 51.5% were women, and 59.3% were white. Hospital DNR rates varied (median, 15.8%; 25th-75th percentile, 8.9%-22.3%). Without accounting for patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality (adjusted odds ratio [OR] for highest-quartile DNR rate vs lowest quartile, 1.17; 95% CI, 1.04-1.32), corresponding to worse hospital mortality rankings. In contrast, after accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, hospitals with higher DNR rates had lower mortality (adjusted OR for highest-quartile DNR rate vs lowest quartile, 0.79; 95% CI, 0.70-0.89), with reversal of associations between hospital mortality rankings and DNR rates. Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment. Hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia (r = 0.11; P = .052); however, DNR rates were positively correlated with patient satisfaction scores (r = 0.35; P < .001).

Conclusions and Relevance  Failure to account for DNR status may confound the evaluation of hospital quality using mortality outcomes, penalizing hospitals that admit a greater proportion of patients with limits on life-sustaining treatments. Stakeholders should seek to improve methods to standardize and report DNR status in hospital discharge records to allow further assessment of implications of adjusting for DNR in quality measures.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Figures

Place holder to copy figure label and caption
Figure 1.
Range of Hospital Early Do-Not-Resuscitate (DNR) Order Rates

Hospitals (n = 303) are ranked in the order of increasing DNR rates. Solid line indicates mean DNR rate of individual hospitals.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Association Between Risk-Standardized Hospital Do-Not-Resuscitate (DNR) Order Rates and Risk-Standardized Hospital Mortality Rates

Regression results exclude 2 outlier hospitals with greater than 50% DNR use rates. A, Spearman r = 0.243 (P < .001). Correlation results were unchanged (Spearman r = 0.243; P < .001) when the 2 outlier hospitals were included. B, Spearman r = −0.09 (P = .12). Correlation results were similar (Spearman r = −0.08; P = .14) when the 2 outlier hospitals were included. C, Spearman r = −0.162 (P = .005). Correlation results were similar (Spearman r = −0.171; P = .003) when the 2 outlier hospitals were included. D, Spearman r = −0.162 (P = .005). Correlation results were similar (Spearman r = −0.149; P = .009) when the 2 outlier hospitals were included.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Risk-Standardized Hospital Mortality Rates Resulting From Model Adjusted and Unadjusted for Patient Do-Not-Resuscitate (DNR) Status

Line demonstrates theoretical line of unity where hospital mortality from the model with DNR adjustment would equal mortality without DNR adjustment (y = x). Diamonds represent hospitals that were not outliers. All triangles represent significant low-performing outlier hospitals from the model unadjusted for patient DNR status. All circles represent significant high-performing hospitals from the model unadjusted for patient DNR status. Open triangles and circles represent hospitals no longer identified as outlier hospitals after adjustment for DNR status.

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

2,465 Views
2 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

Care at the Close of Life: Evidence and Experience
Beyond Advance Directives: Importance of Communication Skills for Care at the End of Life

Care at the Close of Life: Evidence and Experience
Advance Directives

brightcove.createExperiences();