Abstract 19: Hospital Level Variation in Do-Not-Resuscitate Orders for Ischemic Stroke Patients: Implications for National Hospital Comparisons
Background: The Center for Medicare and Medicaid Services (CMS) plans to publicly report hospital-level adjusted ischemic stroke mortality as a marker of hospital quality. Do-not-resuscitate (DNR) orders, which are a well-known predictor of mortality after stroke, are not accounted for in the current CMS risk-adjustment model.
Methods: Using the California State Inpatient Database from 2005-2011, ischemic stroke admissions (primary ICD-9 codes 433.x1, 434.x1, 436) over age 50 were identified. Cases were categorized by the presence/absence of a DNR order within the first 24 hours of admission. Multi-level logistic regression with a random hospital intercept was used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors and demographics. Hospital mortality rank order was assigned based on this model and compared to the results of a second model that included DNR status.
Results: From 356 hospitals, 261,921 cases were identified: 34,436 with early DNR (13.1%) and 227,485 without (86.9%). 43.1% of all mortality occurred in patients with DNR orders. Hospital-level utilization of DNR varied widely (quintile 1, 2.5% vs. quintile 5, 30.7%; p < 0.001). Compared to a model with DNR, a model not accounting for DNR overestimated mortality by at least 1% (absolute) in 36 hospitals (maximum change 2.4%) and underestimated mortality by at least 1% (absolute) in 15 hospitals (maximum change 1.8%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum (Figure).
Conclusions: There is wide variation in the hospital-level proportion of ischemic stroke patients with DNR orders. To the extent variation in hospital-level DNR orders represents variation in patient preferences, CMS risk-adjusted mortality measures may result in hospital misclassification, and specifically punish hospitals treating a high proportion of patients who prefer lower intensity treatment.
Author Disclosures: A.G. Kelly: None. D.B. Zahuranec: Honoraria; Modest; American Academy of Neurology for speaking on end-of-life decisions in stroke. Research Grant; Significant; NIH/NIA K23AG038731. R.G. Holloway: None. J.F. Burke: Research Grant; Significant; NIH/NINDS K08NS082597.
- © 2014 by American Heart Association, Inc.