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Hospitals Penalized in Rankings for High Percentage of DNR Orders

BOSTON – Hospitals that attract a larger proportion of patients with “do not resuscitate” (DNR) orders might have much higher quality levels than their rankings suggest.

That’s according to a study appearing recently in JAMA Internal Medicine. Boston University School of Medicine researchers examined how hospital differences in patient preferences for life-sustaining treatments, such as DNR orders, affected hospital rankings for pneumonia. They found that including patient decisions about life-sustaining treatments in the statistical mortality models potentially lowered hospital rankings, affecting hospital ratings which, in turn, had an effect on reimbursements and financial penalties.

"Our findings suggest that current methods of comparing hospitals, which do not account for patient DNR status, penalize potentially high-quality hospitals admitting a larger proportion of patients who had chosen to forgo resuscitation,” explained corresponding author Allan Walkey, MD, MS. “Therefore, accounting for DNR status in programs that compare hospital mortality outcomes may substantially affect publicly reportable hospital rankings and hospital reimbursements.”

The retrospective, population-based cohort study was conducted among adults hospitalized with pneumonia in 303 California hospitals between Jan. 1 and Dec. 31, 2011. Of the 90,644 pneumonia cases (5.4% of admissions) identified, the mean age was 72.5 and the majority of patients were female and white.

Hospital DNR rates varied, according to the results which found that, without accounting for individual patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality, with an adjusted odds ratio of 1.17. After accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, however, the study determined that hospitals with higher DNR rates actually had lower mortality -- an adjusted OR of 0.79.

“Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment,” the authors wrote, adding that hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia but were positively correlated with patient satisfaction scores.

The researchers called for improvement of methods to standardize and report DNR status in hospital discharge records and how that is considered in hospital rankings.

“Without accounting for patient preferences for life-sustaining treatments, hospitals admitting more patients who chose a 'DNR' status appeared to be poorer quality hospitals for patient mortality measures,” Walkey added in a Boston University press release. “However, our results suggested the opposite: Hospitals with a larger number of patients who chose 'DNR' status tended to have greater patient satisfaction, high performance on measures of pneumonia care, and lower mortality after accounting for patient 'DNR' preferences.”

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