Variation in Do-Not-Resuscitate Orders and Implications for Heart Failure Risk-Adjusted Hospital Mortality Metrics.
Variation in Do-Not-Resuscitate Orders and Implications for Heart Failure Risk-Adjusted Hospital Mortality Metrics.
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DOI：
10.1016/j.jchf.2017.07.010
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发表时间：
2017-10
期刊：
影响因子：
--
通讯作者：
Walkey AJ
中科院分区：
文献类型：
--
作者：
Bruckel J;Mehta A;Bradley SM;Thomas S;Lowenstein CJ;Nallamothu BK;Walkey AJ
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。禁止复苏令限制了维持生命疗法的使用。接受DNR命令的患者增加了住院死亡率，不同医院的DNR率有所不同。DNR率的变化可能会严重混淆心衰风险调整后的医院死亡率。我们通过2011年加利福尼亚州住院患者数据库确定了一组初步诊断为心力衰竭的成年人，该数据库是入院24小时内捕获“早期DNR”的索赔数据库。采用随机效应logistic回归确定医院级风险标准化住院死亡率。我们探讨了具有和不具有早期DNR状态的模型中离群值状态的变化。290家医院的55,865例心力衰竭住院患者中，12.1%（11.8%至12.4%）有早期DNR命令。风险标准化DNR率较高的医院风险标准化死亡率较高（ρ = 0.241； 95%可信区间[CI]: 0.129 ~ 0.346; p < 0.001）。在用于基准医院死亡率的模型中加入DNR可提高模型性能（c-统计量从0.821 [95% CI: 0.812至0.830]到0.845 [95% CI: 0.837至0.853]；模型解释力提高17%）。纳入DNR导致9.3%的医院异常状态重新分类。有和没有DNR的模型在医院离群值指定上的一致性为低到中等（kappa系数：0.492;95% CI: 0.331 ~ 0.654）。考虑DNR状态导致估计风险标准化死亡率和将医院分类为“异常值”的变化。鉴于心力衰竭死亡率测量的公开报告及其对报销的影响，应考虑在质量测量中考虑早期DNR订单的存在。
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.
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影响因子：
--
作者：
Jackson, EA;Yarzebski, JL;Gore, JM
通讯作者：
Gore, JM
影响因子：
8.8
作者：
Bradford MA;Lindenauer PK;Wiener RS;Walkey AJ
通讯作者：
Walkey AJ
影响因子：
6
作者：
Phadke, Anuradha;Heidenreich, Paul A.
通讯作者：
Heidenreich, Paul A.
DOI：
10.1046/j.1532-5415.2002.50620.x
发表时间：
2002-12-01
影响因子：
6.3
作者：
Beach, MC;Morrison, RS
通讯作者：
Morrison, RS
影响因子：
3.4
作者：
Seymour, Christopher W.;Iwashyna, Theodore J.;Cooke, Colin R.
通讯作者：
Cooke, Colin R.