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Cited by 61Palliative Care and End-of-Life IssuesPrimary Care and Health OutcomesHealthcare Quality and Management

Association of do-not-resuscitate orders and hospital mortality rate among patients with pneumonia

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Walkey, Allan J., Weinberg, Janice, Wiener, Renda Soylemez, Cooke, Colin R., Lindenauer, Peter K.·2016·JAMA Internal Medicine
DOI 10.1001/jamainternmed.2015.6324PMC PMC6684128
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Abstract

IMPORTANCE: Hospital quality measures that do not account for patient do-not-resuscitate (DNR) status may penalize hospitals admitting a greater proportion of patients with limits on life-sustaining treatments. OBJECTIVE: To evaluate the effect of analytic approaches accounting for DNR status on risk-adjusted hospital mortality rates and performance rankings. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, population-based cohort study was conducted among adults hospitalized with pneumonia in 303 California hospitals between January 1 and December 31, 2011. We used hierarchical logistic regression to determine associations between patient DNR status, hospital-level DNR rates, and mortality measures. Changes in hospital risk-adjusted mortality rates after accounting for patient DNR status and interhospital variation in the association between DNR status and mortality were examined. Data analysis was conducted from January 16 to September 16, 2015. EXPOSURES: Early DNR status (within 24 hours of admission). MAIN OUTCOMES AND MEASURES: In-hospital mortality, determined using hierarchical logistic regression. RESULTS: A total of 90,644 pneumonia cases (5.4% of admissions) were identified among the 303 California hospitals evaluated during 2011; mean (SD) age of the patients was 72.5 (13.7) years, 51.5% were women, and 59.3% were white. Hospital DNR rates varied (median, 15.8%; 25th-75th percentile, 8.9%-22.3%). Without accounting for patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality (adjusted odds ratio [OR] for highest-quartile DNR rate vs lowest quartile, 1.17; 95% CI, 1.04-1.32), corresponding to worse hospital mortality rankings. In contrast, after accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, hospitals with higher DNR rates had lower mortality (adjusted OR for highest-quartile DNR rate vs lowest quartile, 0.79; 95% CI, 0.70-0.89), with reversal of associations between hospital mortality rankings and DNR rates. Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment. Hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia (r = 0.11; P = .052); however, DNR rates were positively correlated with patient satisfaction scores (r = 0.35; P < .001). CONCLUSIONS AND RELEVANCE: Failure to account for DNR status may confound the evaluation of hospital quality using mortality outcomes, penalizing hospitals that admit a greater proportion of patients with limits on life-sustaining treatments. Stakeholders should seek to improve methods to standardize and report DNR status in hospital discharge records to allow further assessment of implications of adjusting for DNR in quality measures.

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  • The findings suggest a higher rate of DNACPR use (31%) than identified in previous studies of other respiratory conditions or sepsis.

    “Our findings suggest a higher rate of DNACPR use (31%) than identified in previous studies of other respiratory conditions or sepsis.”

    From Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study (2021) · cites this paper as [9]

    The Results section (Hospital Variation in Early DNR Rates; page unavailable) reports a median hospital early DNR rate of 15.8% among patients with pneumonia, providing a lower rate from a respiratory-condition study for comparison with the citing authors’ 31% finding. The paper does not report a comparable DNR-use rate for sepsis, so it does not support that part of the comparison. (LLM, conf=0.78)

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  • Studies of patients admitted with community-acquired pneumonia reported rates of DNACPR use ranging from 13% to 29%.

    “Studies of patients admitted with community-acquired pneumonia reported rates of DNACPR use ranging from 13% to 29%,6, 7, 8, 9, 10”

    From Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study (2021) · cites this paper as [9]

    The Results section reports a median hospital early-DNR rate of 15.8% among patients hospitalized with pneumonia, which falls within the cited range. It does not report rates spanning 13% to 29%, and the Methods section does not specifically identify the cohort as having community-acquired pneumonia. No page number is available in our copy. (LLM, conf=0.85)

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  • Previous studies have estimated the prevalence of DNACPR decision in patients admitted to hospital with community-acquired pneumonia and sepsis, and have attempted to identify factors associated with DNACPR use, but we currently know very little about how DNACPR decisions have been used in people admitted with suspected COVID-19.

    “Previous studies have estimated the prevalence of DNACPR decision in patients admitted to hospital with community-acquired pneumonia6, 7, 8, 9, 10 and sepsis,11, 12, 13, 14 and have attempted to identify factors associated with DNACPR use, but we currently know very little about how DNACPR decisions have been used in people admitted with suspected COVID-19.”

    From Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study (2021) · cites this paper as [9]

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Authors
Walkey, A. J., Weinberg, J., Wiener, R. S., Cooke, C. R., & Lindenauer, P. K.
Affiliations
  • Boston University (US)
  • University of Michigan (US)
  • Tufts University (US)
Corresponding author
Walkey, Allan J.
ORCID
Venue
JAMA Internal Medicine
Publisher
American Medical Association (AMA)
Published
2016-01-01
Volume
176
Issue
1
Pages
97
ISSN
2168-6106 (ISSN-L)
DOI
10.1001/jamainternmed.2015.6324
PMC
PMC6684128
OpenAlex
W2207278592
Cited by
61
References
40
Citations by year
2026: 8 · 2025: 3 · 2024: 2 · 2023: 4 · 2022: 2 · 2021: 9 · 2020: 6 · 2019: 4 · 2018: 8 · 2017: 7 · 2016: 7 · 2015: 1
FWCI
8.22
Type
journal article
Language
en
Open access
Locations
  • JAMA Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health
  • Agency for Healthcare Research and Quality (K08HS020672)
  • National Heart, Lung, and Blood Institute (K01HL116768)
  • National Cancer Institute (K07CA138772)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
  • Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
Keywords
do-not-resuscitate orders, pneumonia, in-hospital mortality, risk adjustment, hospital rankings, hospital quality indicators, life-sustaining treatment, interhospital variation, California hospitals
MeSH terms
Aged, Aged, 80 and over, California, Female, Humans, Male, Middle Aged, Pneumonia, Retrospective Studies, Cohort Studies, Logistic Models, Odds Ratio, Resuscitation Orders, Hospital Mortality, Quality Indicators, Health Care

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