BUSM researchers explore how do not resuscitate orders affect hospital rankings for pneumonia

Healthcare consumers, policy and insurance organizations rely heavily on hospital ranking reports, but how accurate are they? Do differences in patient preferences for life-sustaining treatments that exist between different hospitals affect how hospitals are ranked?

Researchers from Boston University School of Medicine (BUSM) examined how hospital differences in patient preferences for life-sustaining treatments (do not resuscitate, or DNR, orders) affected hospital rankings for pneumonia. They found that including patient decisions about life-sustaining treatments in the statistical models used to determine hospital mortality rankings resulted in substantial changes to hospital rankings that could affect hospital ratings, and reimbursements and financial penalties. This study appears in the JAMA Internal Medicine.

"Our findings suggest that current methods of comparing hospitals, which do not account for patient DNR status, penalize potentially high-quality hospitals admitting a larger proportion of patients who had chosen to forego resuscitation. Therefore, accounting for DNR status in programs that compare hospital mortality outcomes may substantially affect publicly reportable hospital rankings and hospital reimbursements," explained corresponding author Allan Walkey, MD, MSc, assistant professor of medicine at Boston University School of Medicine and a pulmonary, allergy, sleep & critical care physician at Boston Medical Center.

According to Walkey these findings have significant ramifications for methods used to assess patient outcomes and hospital quality. "Without accounting for patient preferences for life-sustaining treatments, hospitals admitting more patients who chose a 'DNR' status appeared to be poorer quality hospitals for patient mortality measures. However, our results suggested the opposite: hospitals with a larger number of patients who chose 'DNR' status tended to have greater patient satisfaction, high performance on measures of pneumonia care, and lower mortality after accounting for patient 'DNR' preferences. Our results also demonstrate the importance of collecting data regarding patient decisions for life-sustaining care and accounting for these decisions when comparing hospitals. Improving our ability to determine hospital 'quality' will facilitate efforts to improve care for all patients," he added.