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

Abstract

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.

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.

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.

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