Should Do-Not-Resuscitate Status be Included as a Mortality Risk Adjustor?
- 1 July 2005
- journal article
- Published by Ovid Technologies (Wolters Kluwer Health) in Medical Care
- Vol. 43 (7), 658-666
- https://doi.org/10.1097/01.mlr.0000167106.09265.4e
Abstract
Background: The practice of ordering “Do-Not-Resuscitate” (DNR) varies across hospitals. No research has explored how the DNR variation would affect cross-institutional performance reporting when DNR status is used as a risk adjustor. Objective: We sought to assess the impact of DNR variation on performance reporting. Research Design: We used retrospective clinical data abstracted from chart review for our analysis. Subjects: We studied a total of 184,057 adult patients admitted to 149 Pennsylvania acute-care hospitals in 2001 for ischemic stroke, hemorrhagic stroke, pneumonia, acute myocardial infarction, congestive heart failure, and sepsis. Measures: DNR rate and DNR mortality rate per patient at the hospital level was assessed. DNR also was used as an additional covariate to predict mortality in logistic regression models. Change of rank and outlier-status at the hospital level based on adjusted mortality determined by multivariable logistic models with or without DNR was used to assess the impact of DNR on performance reporting. Results: Large variations in DNR rates (1–37%) and DNR mortality rates (8–60%) existed across hospitals. There was a significant negative correlation between DNR rates and DNR mortality rates (r = −0.66, P < 0.0001). Adding DNR as a covariate resulted in a systematic shift in performance rank (r = 0.88, P < 0.0001) and change in statistical outlier-status (n = 33), which favored hospitals with higher DNR rates. Conclusion: Using locally defined DNR as an additional covariate potentially introduces systematic bias in performance reporting. A more uniform definition and application of DNR is needed if it is to be included as a risk adjustor.Keywords
This publication has 17 references indexed in Scilit:
- Do Patients Die Because They Have DNR Orders, or Do They Have DNR Orders Because They Are Going to Die?Medical Care, 1999
- A Spurious Correlation Between Hospital Mortality and Complication RatesMedical Care, 1997
- A Prediction Rule to Identify Low-Risk Patients with Community-Acquired PneumoniaThe New England Journal of Medicine, 1997
- Judging hospitals by severity-adjusted mortality rates: the influence of the severity-adjustment method.American Journal of Public Health, 1996
- Medis Groups Data BasesMedical Care, 1993
- Hospital and Patient Characteristics Associated With Death After SurgeryMedical Care, 1992
- Predicting In-Hospital MortalityMedical Care, 1992
- Admission and mid-stay MedisGroups scores as predictors of death within 30 days of hospital admission.American Journal of Public Health, 1991
- A clinical assessment of MedisGroupsJAMA, 1988
- The central role of the propensity score in observational studies for causal effectsBiometrika, 1983