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Study Questions Use of Mortality as Measure of Stroke Care

Early DNR orders can skew hospitals’ quality rankings (February 12)

A new study disputes the effectiveness of mortality as a measure of the quality of care provided by hospitals to stroke patients. The paper — which was simultaneously presented at the International Stroke Conference in San Diego and published in the journal Stroke — found that the use of do-not-resuscitate (DNR) orders differ widely between hospitals and that this variation can significantly skew a hospital’s “quality ranking” based on mortality.

The national movement toward measuring and publicly reporting quality-of-care data and — in the case of the federal government — linking this information to payment has spurred a discussion in the medical community over which metrics accurately reflect how well an institution is doing.

One such example is the use of 30-day risk-adjusted mortality for stroke, which has been used by organizations such as Healthgrades as one of the primary indicators of a hospital’s quality of stroke care.

In the new study, researchers examined data on 252,368 stroke cases at hospitals in California during the 6-year period between 2005 and 2011.

The investigators found a wide range of variation in the use of early DNRs (those placed within the first 24 hours of admission), with the lowest group of hospitals using DNRs in an average of 2.2% of stroke cases, whereas the highest group used the orders an average of 23.2% of the time — a ten-fold difference. As would be expected, the hospitals with a greater percentage of DNRs generally had higher mortality rates.

The researchers then plotted each hospital’s rank in mortality both with and without DNRs. As many as 28% of the hospitals that were ranked as poor performers in stroke care when DNRs were not accounted for were reclassified to average performers when DNRs were taken into account. Conversely, other hospitals that were ranked as average performers were reclassified to low performers once DNRs were accounted for.

“We have this factor — early DNR utilization — that varies widely among hospitals and clearly impacts hospital mortality and rankings based on mortality, and yet we lack the ability to understand when these early DNRs are used in a high quality, patient-centered fashion versus when they are not,” said investigator Adam G. Kelly, MD. “These results should be a clear indication that we need to take a ‘go slow’ approach when it comes to using mortality as a metric to measure quality of stroke care.”

Source: University of Rochester Medical Center; February 12, 2014.

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