title: Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure.
abstract: BACKGROUND
  Heart failure (HF) is one of the leading causes of morbidity and mortality among Americans. Despite increased interest in end-of-life care, the implications of do-not-resuscitate (DNR) orders in acutely ill patients with HF remain unclear. The goals of this observational study were to describe the use of DNR orders and their impact on treatment approaches in residents of a large New England metropolitan area hospitalized with acute heart failure.
  
  
  METHODS
  Use of HF performance measures, including assessment of left ventricular function, use of angiotensin receptor blocking agents, anticoagulation, smoking cessation counseling, and use of nonpharmacologic strategies, was examined through review of the medical records of 4,537 metropolitan Worcester (MA) residents admitted to 11 central Massachusetts hospitals with acute HF in 1995 and 2000 according to the presence of DNR orders.
  
  
  RESULTS
  Patients with DNR orders were less likely to have had their left ventricular function assessed (31% vs 43%) as well as receive renin-angiotensin system blockade (49% vs 57%), anticoagulation (65% vs 78%), or nonpharmacologic interventions (87% vs 92%) as compared to patients without DNR orders. Patients with DNR orders were significantly less likely to have received any quality assurance measure for acute HF (adjusted hazard ratio 0.63, 95% confidence interval 0.40-0.99) than patients without DNR orders.
  
  
  CONCLUSIONS
  The use of quality assurance measures in acute HF is markedly lower in patients with DNR orders. The implications of DNR orders need to be further clarified in the treatment of patients with acute HF.
authors.affiliation: Renal Section, Boston University School of Medicine, Boston, MA 02118, USA. joline.chen@bmc.org
authors.forename: Joline L T
authors.initials: JL
authors.lastname: Chen
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sosnov
authors.forename: Darleen
authors.initials: D
authors.lastname: Lessard
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Goldberg
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D017052:Hospital Mortality / Q000639:trends*; D006760:Hospitalization; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D011336:Probability; D011785:Quality Assurance, Health Care / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012042:Registries; D016414:Resuscitation Orders; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome