June 9, 2008

Making Mortality Measurement More

MeaningfulIncorporating Advanced Directives and

Palliative Care Designations Eugene A. Kroch, Ph.D.Mark Johnson, M.D., CMO Mercy Health

John Martin, M.P.H., PremierMichael Duan, M.S., Premier

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Community Acquired Pneumonia Outcome Profile (n=397)

Risk Calculation: Select Practice

Data source: CMS 7/1/01-6/30/02* 75% statistical significance** 90% statistical significance

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Mortality Morbidity Complications GM LOS

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Raw Std Select Raw Std Select Raw Std Select Raw Std Select8.3 6.5 5.1 12.4 12.6 10.9 42.2 45.9 42.1 4.8 4.9 4.1

GM LOSMortality Morbidity Complications

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The Issue

• In-hospital mortality measurement may be improved by taking into account “Do Not Resuscitate” (DNR) orders and “Palliative Care” (PC) designations.

• Previous research in a single facility (Kroch-Samaha, Cooper University Hospital, 2005) demonstrated that DNR orders were significantly related to in-hospital mortality risk

• NB: Cooper study did not have reliable PC data.

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Study Objectives• Primary Objective:

– Assess the value of incorporating DNR and PC information in the Wharton/CareScience mortality model (Medical Care)

• Secondary Objectives:

– Characterize the incidence of DNR and PC by service line and physician type

– Characterize the incidence of DNR and PC among patient types, e.g. age, disease/treatment, gender, transfer status, financial class, admit type, etc.

– Evaluate the relationship between DNR and PC orders and inpatient mortality

– Explore the DNR timing dimension with respect to the above

– Explore the relationship between DNR and PC

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Study Sample• Facility: Mercy Health Center in Oklahoma City • Timeframe: 9/2005 - 10/2006

• Patient Data: – All discharges– DNR patients: All patients that signed DNR’s during

hospitalization from 9/05 – 10 /06– Palliative Care patients: All patients with palliative

care consult order

• Model calibration on 265 hospitals in 38 states, 4.5 millions discharges over two years.

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Informational Realities

Strength Weakness

PC Strong association with mortality risk

Lack of defined standards for identifying PC patients

(inconsistent use of V66.7 code)

DNR Common usage across facilities, systems, and states

Not consistently captured in electronic record systems;

Timing dependency

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Hospital Palliative Care RateCoding Variation

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2 4 6 8 10 12 14 16 18 20 22 24 26 28

Palliative Care Rate per Thousand

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Half of hospitals have less than 2 per thousand

Distribution of Palliative Care Coding Among Premier QUEST Hospitals

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Hospital Mortality Rates for Patients under Palliative Care

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Mortality Rate

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Mean = 53%

Palliative Care Mortality Distribution among Premier QUEST Hospitals

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Summary of Findings:– DNR and PC patients systematically differ from

other patients.

– PC and DNR can and should be incorporated into a mortality risk model.

• PC/DNR information explains some of patient risk at the margin (after accounting for other mortality risk factors already in the CareScience model)

• The marginal contribution of PC/DNR information to mortality risk depends on other patient attributes (diagnosis, age, etc.)

• PC in itself is a very strong risk indicator and DNR less so.

– ACTION: Improve PC and DNR documentation to be consistent across hospitals (and service lines).

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How are DNR/PC patients different from other hospital inpatients?

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Patients by Service

N=2059 N=928 N=917 N=775 N=684 N=668 N=572 N=458 N=398 N=2795 N=6229

The proportion of DNR/PC patients varies by service.

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DNR + PC Patients DNR Only Patients

N=2059 N=928 N=917 N=775 N=684 N=668 N=572 N=458 N=398 N=2795 N=6229

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ER PhysicianReferral

HospitalTransfer

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DNR Non-DNR

Patients by Admit Source

N=4894 N=3653 N=538 N=32 N=12

Hospital transfers and emergent patients are over-represented among DNR patients.

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Age (Midpoint)

Palliative Cases Non-Palliative Cases

Age distribution

N=471 N=261 N=332 N=354 N=527 N=677 N=805 N=759 N=838 N=904 N=945 N=947 N=808 N=358 N=130 N=22

The proportion of DNR patients rises with age.

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Where is the mortality deviation for DNR/PC patients greatest?

NB: Where mortality deviation is greatest is where the model’s mortality prediction would potentially be most affected by including DNR/PC information.

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Mortality Deviation by Age

Mortality Rate of DNR Population by Age

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Patient count Mortality Deviation

The mortality deviation is greater among younger DNR patients.

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Mortality Deviation by Service*

*Results shown for Attendings with >2% of all cases

Mortality Rate of DNR Population by Attending Physician

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Mortality deviation is greater for GI, Oncology, Cardiology.Mortality Rate of DNR Population by Attending Physician

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Mortality deviation is greater for GI, Oncology, Cardiology.

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Mortality Deviation of Hospitalists

Mortality Rate of DNR Population by Hospitalist Status

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Mortality deviation is less among hospitalists.Hospitalists have a higher proportion of DNR patients (slide 13).

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Mortality Deviation of DNR/PC Population by Order Day

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DNR + PC Patient DNR Only Patients ALL DNR Patients

Mortality Deviation by Order TimingThe later the PC/DNR order, the greater the Mortality deviation.

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Adding DNR/PC to the Model• Modeling the Mortality Rate

– DNR alone explains 23% - 45% of mortality variation within disease group. Adding PC increases the explained variation to 31% - 55%.

– The CareScience risk model alone explains 30% to 54% of mortality variation. Adding DNR and PC to the model increases explained variation to 38% - 65%.

• Modeling Mortality Deviation– DNR/PC explains 8% – 40% of the variation in mortality

deviation (raw – risk), depending on disease group.

– Issuance of a DNR order later in the hospital stay was associated with a higher mortality rate.

Regression Analysis Summary

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Relative Explanatory PowerPneumomia &

Septicemia OncologyHeart

DiseasesDigestive Diseases

Observed MortalityStandard 0.31 0.47 0.54 0.30DNR 0.23 0.45 0.31 0.25DNR+PC 0.31 0.49 0.55 0.46Standard+DNR 0.38 0.57 0.63 0.44Standard+DNR+PC 0.39 0.58 0.65 0.61

Mortality GapDNR 0.08 0.24 0.23 0.15DNR+PC 0.08 0.24 0.40 0.36

DNRStandard 0.36 0.48 0.39 0.27

PCStandard 0.60 0.94 0.82 0.24

Proportion of outcome variation explained by models for selected populations

MODEL

R-squared or Derived R-squared is displayed for each modelStandard = age (birth weight for neonates), sex, race, income, relative distance traveled, principal diagnosis, CACR comorbidity score , defining diagnosis, cancer status, chronic disease and disease history, valid procedures, admission source, admission type, payer class, and facility typeDNR = do not resuscitate indicatorPC = palliative care indicator

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Marginal Effects for Selected Conditions

Pneumomia &

Septicemia OncologyHeart

DiseasesDigestive Diseases

Dnr_post_admit1 <=1 Day 0.07 0.29 0.13 0.19

Dnr_post_admit2 2 - 5 Days 0.23 0.25 0.14 0.27

Dnr_post_admit3 >5 Days 0.18 0.42 0.28 0.35Palliative Care 0.09 0.26 0.50 0.57Marginal Impact at mean - all coefficients are significant at p<0.01

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Explaining DNR…• Modeling DNR with CareScience risk factors

– CareScience risk factors explain 36% - 48% of DNR orders, indicating relatively high correlation (60% - 70%) between DNR and the standard set of CareScience risk factors.

– The interaction between age and DNR was particularly strong in the Circulatory Disease group. The younger a patient was the higher mortality rate. Among Cancer patients, the interaction was the opposite.

NOTE: Within the data set that we received from OKLC, V667 did NOT always correspond to the palliative care flag.

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Conclusion• Actual and expected mortality rates for DNR/PC patients are higher

than non-DNR patients.

• Some aspects of risk associated with DNR & PC are captured in the CareScience model, but not all.– Hence, risk assessment can be improved by adding DNR & PC

indicators.

• Adding DNR and PC indicators into a risk assessment model will have the greatest impact on certain sub-populations (e.g., younger patients and selected diagnostic groups).

• Patients with DNR orders later in their stay have higher mortality rates (and higher mortality deviations). This observation raises the danger that accounting for DNR in such patients may mask opportunities for better care.

• ACTION: Improve PC and DNR documentation to be consistent across hospitals (and service lines).