Association of Do-Not-Resuscitate Patient Case Mix With Publicly Reported Risk-Standardized Hospital Mortality and Readmission Rates

Abstract

IMPORTANCE The Centers for Medicare and Medicaid Services's (CMS's) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings. OBJECTIVE To identify the association between hospital-level DNR prevalence and conditionspecific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis. EXPOSURES Present-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions. MAIN OUTCOMES AND MEASURES Hospital-level 30-day RSMRs and RSRRs for 5 conditionspecific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no). RESULTS Included in the study were 4 884 237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2 608 182 women [53.4%]) and 4 450 378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P < .001). The inverse was true among the readmission cohorts, with the highest quintiles of DNR prevalence exhibiting the lowest RSRRs (eg, AMI: 15.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

“…The existence of “do not resuscitate” orders has increased with time [ 142 ], although a wide range of prevalence has been reported [ 143 , 144 , 145 ]. Only very few guidelines on writing DNR orders—the “when and how”—are available, e.g., by professional medical societies [ 21 ].…”

State and Government Administrative Databases

“…Numerous quality measures central to charting hospital performance can be examined using these files, including 30-day readmissions, mortality, home discharge, and compli-cations following total hip or knee arthroplasty, to name a few notable examples. As an illustration, Pollock et al utilized the SAFs to examine the association of the do-not-resuscitate patient case mix with risk-standardized hospital mortality and readmissions rates that are publicly reported 7 .…”

Implications of Including Hospital Do-Not-Resuscitate Rates in Risk Adjustment for Pay-for-Performance Programs

“…Using national Medicare data, the study by Pollock and colleagues showed that higher hospital prevalence of a do-not-resuscitate (DNR) status that is present on admission (POA) may be associated with higher risk-standardized mortality rates but lower risk-standardized readmission rates across several clinical conditions, leading to a lower likelihood of penalization under the Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program (HRRP). The authors recommended that hospital prevalence of POA DNR status should be included in pay-for-performance risk-adjustment calculations.…”

“…The implicit assumption is that hospitals with low prevalence of POA DNR status unfairly receive penalties, whereas hospitals with high prevalence of POA DNR status inadvertently get rewarded by the HRRP. Pollock and colleagues should be applauded for their thoughtful, well-designed analysis and their desire to improve performance measures. However, it is important to critically appraise their assumption that including POA DNR prevalence in risk-adjustment models will improve the ability to accurately and fairly assess quality.…”

“…What might be the implications, then, of including hospital prevalence of POA DNR status in risk adjustment for HRRP or other pay-for-performance programs, as Pollock and colleagues suggested? Hospitals with a high prevalence of POA DNR status, which tend to have higher mortality and lower readmission rates, would be at risk of incurring greater financial penalties under the HRRP.…”