Quality reporting needs to consider DNR impact on mortality

Failing to account for patients with do-not-resuscitate (DNR) orders when calculating mortality for hospital quality measures could result in unfair penalties for some hospitals, according to a study published online in JAMA Internal Medicine.

After accounting for patient DNR status of pneumonia patients and variations between hospitals, organizations with higher DNR rates had lower mortality, according to the study abstract. Only 52 percent of hospitals initially characterized as low-performing outliers because of their mortality numbers remained outliers after adjusting for DNR status, researchers said.

The paper recommended developing ways to standardize and report DNR status in hospital discharge records as a step toward adjusting for DNR in quality measures.

"Although the results of this study are relatively straightforward, the interpretation and implications are anything but," Leora I. Horwitz, M.D., wrote in a commentary accompanying the study, adding, "There is no easy resolution to this conundrum."

"None of Medicare's publicly reported mortality measures includes do-not-resuscitate (DNR) status in risk adjustment, largely because such data are not routinely reported by hospitals, but also in part because of an underlying assumption that the increased mortality risk of such patients can be accounted for by comorbidity adjustment," she wrote in the commentary.

A 2011 study found that patients who signed DNR orders may be more likely to die after surgery, FierceHealthcare reported at the time. Regardless of the urgency of the procedure, patients with DNR orders were at least twice as likely to die soon after surgery as those without DNRs. Additionally, nearly one-fourth of the DNR patients died less than a month after surgery, three times higher than the comparison group.

To learn more:
- here's the study
- read the commentary (subscription requiired)