Background — Pay for performance programs compare metrics that are risk-adjusted, but goals of care are not considered in current models. The researchers conducted this study to explore the associations between DNR designations, quality of care, and outcomes.
Methods and Results — Retrospective cohort study with chart review for inpatient quality metrics, 30 day mortality, and re-admissions and/or death within 30 days of discharge in 96 Ontario hospitals participating in the Enhanced Feedback For Effective Cardiac Treatment study in 2004/05. Of 8,339 patients (mean age 77 years) with new heart failure (HF), 1,220 (15%) had DNR documented at admission (“Admission DNR”, varying from 0% to 36% between hospitals) and 892 (11%) were switched from full resuscitation to DNR during their index hospitalization (“Later DNR”). Death at 30 days was more common in patients with Admission DNR (27%) or Later DNR (35%) than full resuscitation (3%) – Admission DNR was a stronger predictor (adjusted OR 8.6, 95%CI 6.8-10.7) than any of the variables currently included in HF 30 day mortality risk models. Hospital-level rankings differed considerably if DNR patients were excluded: 22 of the 39 EFFECT hospitals in the top and bottom quintiles for 30 day mortality rates (the usual thresholds for rewards/penalties in current performance-based reimbursement schemes) would not have been in those same quintiles if Admission DNR patients were excluded.
Conclusions — Alternate goals of care are frequent and important confounders in HF comparative studies. Philosophy of care discussions should be considered for inclusion as a potential quality of care indicator.
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Research and statistical methods