title: Association of Do-Not-Resuscitate Orders and Hospital Mortality Rate Among Patients With Pneumonia.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Early DNR status (within 24 hours of admission).
  
  
  METHODS
  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
  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.
authors.affiliation: The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Walkey
authors.affiliation: Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts.
authors.forename: Janice
authors.initials: J
authors.lastname: Weinberg
authors.affiliation: The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts3Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedfo.
authors.forename: Renda Soylemez
authors.initials: RS
authors.lastname: Wiener
authors.affiliation: Division 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.
authors.forename: Colin R
authors.initials: CR
authors.lastname: Cooke
authors.affiliation: Center for Quality of Care Research, Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts7Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002140:California / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011014:Pneumonia / Q000401:mortality*; D019984:Quality Indicators, Health Care; D016414:Resuscitation Orders; D012189:Retrospective Studies