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Current ways to risk-adjust heart failure mortality as a measure of hospital-level quality are insufficient, suggested a study showing that accounting for do-not-resuscitate (DNR) orders reshuffles institutional rankings.

Hospitals in California had a median 8.7% rate of DNR orders among heart failure patients, ranging from 0% to 53.8%. A DNR order initiated within 24 hours of admission was associated with greater odds of in-hospital death (9.9% versus 2.1% without DNR, adjusted RR 3.63, 95% CI 3.17-4.16). Hospitals with more DNR patients reported higher risk-standardized mortality (P<0.001).

Accordingly, DNR status to benchmark hospital mortality. The c-statistic increased from 0.821 to 0.845, yielding 17% additional model explanatory power, Jeffrey Bruckel, MD, MPH, of New York's University of Rochester Medical Center, and colleagues reported in the October issue of JACC: Heart Failure.

Moreover, accounting for DNR orders reduced the number of outliers -- hospitals with greater mortality than expected for their case mix -- down from 22 to 14.

"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," the investigators suggested.

One such tie with reimbursement is the CMS Value-Based Payment System, which takes 2% of group payments and redistributes it according to hospital performance.

"Currently, a 13% 30-day all-cause mortality rate for heart failure places a hospital in the top 20%, whereas an 11% rate puts them in the bottom 20%," according to an accompanying editorial by Paul Heidenreich, MD, of California's VA Palo Alto Health Care System.

"Although we care about mortality, it is not clear we should care as much about published hospital mortality rates," Heidenreich said, likening them to fatal plane crash rates: "I accept these rates as accurate; but then, why am I more concerned about leg room and in-seat power? I (and I expect most others) feel these small differences in mortality rates are more likely due to chance, and do not represent a systematic safety difference."

Heidenreich emphasized that 30-day heart failure mortality, as a quality measure, is "only as good as its signal-to-noise ratio."

He added, "the signal (variation in mortality due to quality differences) is small compared with the noise (variation in mortality due to everything else). Ironically, as hospitals improve their processes of care, and the quality improves across the board, this signal/noise ratio will only worsen, making 30-day mortality rates even less useful."

The 2011 California State Inpatient Database (SID) accessed by Bruckel's group contain the only administrative claims in the U.S. linked to early DNR orders. The uniqueness of this database, along with some missing data (such as outpatient diagnosis codes), were limitations.

In total, 55,865 patients hospitalized at 290 hospitals were included. Of those, 12.1% had an early DNR order in place. Older patients, women, and those with dementia, metastatic cancer, or leukemia were more likely to have a DNR order.

"Based on median odds ratio results, the hospital to which a patient was admitted was more strongly associated with receipt of a DNR order than the strongest clinical predictors in the model," Bruckel and colleagues wrote. "This finding mirrors previous research demonstrating that DNR use is strongly influenced by patient factors such as race, socioeconomic status, and education, as well as physician and institutional culture and practice norms."

"We clearly need to adopt better measures of the quality of heart failure care. Until then, adjusting mortality for DNR status would be a step in the right direction," Heidenreich concluded.