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

Abstract

Measurement of hospital performance through risk-adjusted mortality and readmission rates is a cornerstone of the US health system, factoring heavily into value-based purchasing and other strategies to incent quality improvement. A key principle underlying such performance measures is risk adjustment, that is, the ability to adjust in statistical models for differences in populations served by hospitals, such as case mix and disease severity, that confer differential risks of adverse outcomes and that may confound comparisons of hospital quality. Yet, identifying which variables to include in risk-adjustment models remains controversial, with different models yielding markedly different assessments of hospital quality. 1 Using national Medicare data, the study by Pollock and colleagues 2 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-forperformance 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

Treatment intensity and mortality among COVID‐19 patients with dementia: A retrospective observational study

“…24 However, a DNR order (which technically specifies no CPR in the event of cardiac arrest) may be the result of many different forces: provider practices (ascertainment of treatment preferences and interpretation of advance directives), underlying patient treatment preferences, and illness severity. 14,19,25 Indeed, a DNR order is often placed when a patient's death is imminent in order to prevent CPR at the time of natural death. 26 Therefore, using a DNR order to explain variation in treatment and outcomes is problematic.…”