Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, New York.
Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health System, Denver, Colorado.
JACC Heart Fail. 2017 Oct;5(10):743-752. doi: 10.1016/j.jchf.2017.07.010.
This study evaluated the effect of patient do-not-resuscitate (DNR) status on hospital risk-adjusted heart failure mortality metrics.
Do-not-resuscitate orders limit the use of life-sustaining therapies. Patients with DNR orders have increased in-hospital mortality, and DNR rates vary among hospitals. Variations in DNR rates could strongly confound risk-adjusted hospital mortality rates for heart failure.
We identified a cohort of adults with primary diagnosis of heart failure by using the 2011 California State Inpatient Database, a claims database that captures "early DNR," within 24 h of admission. Hospital-level risk-standardized in-hospital mortality was determined using random effects logistic regression. We explored changes in outlier status in models with and without early DNR status.
Among 55,865 patients from 290 hospitals hospitalized with heart failure, 12.1% (11.8% to 12.4%) had an early DNR order. Hospitals with higher risk-standardized DNR rates had higher risk-standardized mortality (ρ = 0.241; 95% confidence interval [CI]: 0.129 to 0.346; p < 0.001). Including DNR in models used to benchmark hospital mortality improved model performance (c-statistic from 0.821 [95% CI: 0.812 to 0.830] to 0.845 [95% CI: 0.837 to 0.853]; increased model explanatory power by 17%). Including DNR resulted in reclassification of 9.3% of hospitals' outlier status. Agreement in hospital outlier designation between models with and without DNR was low to moderate (kappa coefficient: 0.492; 95% CI: 0.331 to 0.654).
Accounting for DNR status resulted in a change in estimated risk-standardized mortality rates and classification of hospitals as performance "outliers." Given public reporting of heart failure mortality measurements and their influence on reimbursement, accounting for the presence of early DNR orders in quality measures should be considered.
本研究评估了患者不复苏（DNR）状态对医院风险调整心力衰竭死亡率指标的影响。
不复苏医嘱限制了生命支持治疗的使用。有 DNR 医嘱的患者院内死亡率增加，并且医院之间的 DNR 率存在差异。DNR 率的差异可能会强烈混淆心力衰竭的风险调整后医院死亡率。
我们使用 2011 年加利福尼亚州住院患者数据库（一个捕获入院后 24 小时内“早期 DNR”的索赔数据库），确定了一组主要诊断为心力衰竭的成年人队列。使用随机效应逻辑回归确定医院水平风险标准化院内死亡率。我们在有和没有早期 DNR 状态的模型中探索了异常值状态的变化。
在 290 家医院因心力衰竭住院的 55865 名患者中，12.1%（11.8%至 12.4%）有早期 DNR 医嘱。风险标准化 DNR 率较高的医院死亡率也较高（ρ=0.241；95%置信区间[CI]：0.129 至 0.346；p<0.001）。在用于基准医院死亡率的模型中包含 DNR 可提高模型性能（从 0.821（95%CI：0.812 至 0.830）提高到 0.845（95%CI：0.837 至 0.853）；增加了 17%的模型解释能力）。包含 DNR 导致 9.3%的医院异常值状态重新分类。有和没有 DNR 的模型之间医院异常值的指定协议一致性低至中等（kappa 系数：0.492；95%CI：0.331 至 0.654）。
考虑到 DNR 状态会改变估计的风险标准化死亡率和医院作为绩效“异常值”的分类。鉴于心力衰竭死亡率的测量结果及其对报销的影响，应考虑在质量措施中考虑早期 DNR 医嘱的存在。
