Influence of Patient Goals of Care on Performance Measures in Patients Hospitalized for Heart Failure: An Analysis of the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) Registry

Unintended Consequences of Code Status in the Intensive Care Unit: What Happens After a Do-Not-Resuscitate Order Is Placed? A Retrospective Cohort Study

Background: Some clinicians suspect that patients with do-not-resuscitate (DNR) orders receive less aggressive care. Extrapolation from code status to goals of care could cause significant harm. This study asked the question: Do DNR orders in the intensive care unit (ICU) lead to a decrease in invasive interventions? Methods: This was a retrospective cohort study of ICU patients from three teaching hospitals. All ICU patients were assessed for inclusion. Exclusion criteria were medical futility and death, comfort care, or ICU discharge <48 hours after DNR initiation. Five hundred thirty-six patients met inclusion criteria. One hundred forty-five were included in the final analysis. Primary outcomes were occurrence of invasive interventions after DNR initiation-surgical operation, central line, ventilation, dialysis, or other procedure. Secondary outcomes were antibiotic administration, blood transfusion, mortality, and discharge location. Results: Patients with DNR orders underwent fewer surgical operations (14.5% vs. 31.1%, p = 0.002), but more central lines (42.1% vs. 23.0%, p = 0.009), ventilator use (49.0% vs. 18.9%, p < 0.001), and dialysis (20.0% vs. 4.1%, p = 0.002), compared with patients without DNR orders. Transfusions and antibiotic use decreased similarly over admission for both groups (transfusions: β = 1.25; p = 0.59; and antibiotics: β = 1.44; p = 0.27). Mortality and hospice discharges were higher for DNR patients (p < 0.001.). Conclusions: DNR status did not decrease the number of nonoperative interventions patients received as compared with full code counterparts. Although differences in populations existed, patients with DNR orders were likely to receive a similar number of invasive interventions. This finding suggests that providers do not wholesale limit these options for patients with code status limitations.

Statins and SARS-CoV-2 Infection: Results of a Population-Based Prospective Cohort Study of 469 749 Adults From 2 Canadian Provinces

Background

Small observational studies have suggested that statin users have a lower risk of dying with COVID‐19. We tested this hypothesis in a large, population‐based cohort of adults in 2 of Canada’s most populous provinces: Ontario and Alberta.

Methods and Results

We examined reverse transcriptase–polymerase chain reaction swab positivity rates for SARS‐CoV‐2 in adults using statins compared with nonusers. In patients with SARS‐CoV‐2 infection, we compared 30‐day risk of all‐cause emergency department visit, hospitalization, intensive care unit admission, or death in statin users versus nonusers, adjusting for baseline differences in demographics, clinical comorbidities, and prior health care use, as well as propensity for statin use. Between January and June 2020, 2.4% of 226 142 tested individuals aged 18 to 65 years, 2.7% of 88 387 people aged 66 to 75 years, and 4.1% of 154 950 people older than 75 years had a positive reverse transcriptase–polymerase chain reaction swab for SARS‐CoV‐2. Compared with 353 878 nonusers, the 115 871 statin users were more likely to test positive for SARS‐CoV‐2 (3.6% versus 2.8%, P<0.001), but this difference was not significant after adjustment for baseline differences and propensity for statin use in each age stratum (adjusted odds ratio 1.00 [95% CI, 0.88–1.14], 1.00 [0.91–1.09], and 1.06 [0.82–1.38], respectively). In individuals younger than 75 years with SARS‐CoV‐2 infection, statin users were more likely to visit an emergency department, be hospitalized, be admitted to the intensive care unit, or to die of any cause within 30 days of their positive swab result than nonusers, but none of these associations were significant after multivariable adjustment. In individuals older than 75 years with SARS‐CoV‐2, statin users were more likely to visit an emergency department (28.2% versus 17.9%, adjusted odds ratio 1.41 [1.23–1.61]) or be hospitalized (32.7% versus 21.9%, adjusted odds ratio 1.19 [1.05–1.36]), but were less likely to die (26.9% versus 31.3%, adjusted odds ratio 0.76 [0.67–0.86]) of any cause within 30 days of their positive swab result than nonusers.

Conclusions

Compared with statin nonusers, patients taking statins exhibit the same risk of testing positive for SARS‐CoV‐2 and those younger than 75 years exhibit similar outcomes within 30 days of a positive test. Patients older than 75 years with a positive SARS‐CoV‐2 test and who were taking statins had more emergency department visits and hospitalizations, but exhibited lower 30‐day all‐cause mortality risk.

Perceptions of ICU Care Following Do-Not-Resuscitate Orders: A Military Perspective

Although do-not-resuscitate orders only prohibit cardiopulmonary resuscitation in the case of cardiac arrest, the common initiation of this code status in the context of end-of-life care may lead providers to draw premature conclusions about other goals of care. The aim of this study is to identify concerns regarding care quality in the setting of do-not-resuscitate orders within the Department of Defense and compare differences in perceptions between members of the critical care team.

Design

A cross sectional observational study was conducted.

Setting

This study took place in the setting of critical care within the Department of Defense.

Subjects

All members of the Uniformed Services Section of the Society of Critical Care Medicine were invited to participate.

Interventions

A validated 31-question survey exploring the perceptions of care quality in the setting of do-not-resuscitate status was distributed.

Measurements and Main Results

Exploratory factor analysis was used to categorically group survey questions, and average factor scores were compared between respondent groups using t tests. Responses to individual questions were also analyzed between comparison groups using Fisher exact tests. Factor analysis revealed no significant differences between respondents of different training backgrounds; however, those with do-not-resuscitate training were more likely to agree that active treatment would be pursued (p = 0.024) and that trust and communication would be maintained (p = 0.005). Although 38% of all respondents worry that quality of care will decrease, 93% agree that life-prolonging treatments should be offered. About a third of providers wrongly believed that a do-not-resuscitate order must be reversed prior to an operation.

Conclusions

Although providers across training backgrounds held similar concerns about decreased care quality in the ICU, there is wide belief that the routine and noninvasive interventions are offered as indicated. Those with do-not-resuscitate training were more likely to believe that standards of care continued to be met after code status change.

Hospitalization outcome of heart diseases between patients who received medical care by cardiologists and non-cardiologist physicians: A propensity-score matched study

Background and aims

The effects of physician specialty on the outcome of heart disease remains incompletely understood because of inconsistent findings from some previous studies. Our purpose is to compare the admission outcomes of heart disease in patients receiving care by cardiologists and noncardiologist (NC) physicians.

Methods

Using reimbursement claims data of Taiwan’s National Health Insurance from 2008–2013, we conducted a matched study of 6264 patients aged ≥20 years who received a cardiologist’s care during admission for heart disease. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, and type of heart disease, 6264 controls who received an NC physician’s care were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for complications and mortality during admission for heart disease associated with a cardiologist’s care.

Results

Patients who received a cardiologist’s care had a lower risk of pneumonia (OR = 0.61; 95% CI, 0.53–0.70), septicemia (OR = 0.49; 95% CI, 0.39–0.61), urinary tract infection (OR = 0.76; 95% CI, 0.66–0.88), and in-hospital mortality (OR = 0.37; 95% CI, 0.29–0.47) than did patients who received an NC physician’s care. The association between a cardiologist’s care and reduced adverse events following admission was significant in both sexes and in patients aged ≥40 years.

Conclusion

We raised the possibility that cardiologist care was associated with reduced infectious complications and mortality among patients who were admitted due to heart disease.

Do-Not-Resuscitate Status and Risk-Standardized Mortality and Readmission Rates Following Acute Myocardial Infarction

Background Important administrative-based measures of hospital quality, including those used by Centers for Medicare and Medicaid Services, may not adequately account for patient illness and social factors that vary between hospitals and can strongly affect outcomes. Do-not-resuscitate (DNR) order on admission (within the first 24 hours) is one such factor that may reflect higher preadmission illness burden as well as patients' desire for less-intense therapeutic interventions and has been shown to vary widely between hospitals. We sought to evaluate how accounting for early DNR affected hospital quality measures for acute myocardial infarction. Methods AND RESULTS We identified all patients admitted with acute myocardial infarction using the California State Inpatient Database, which captures early DNR use within 24 hours of admission. We generated hospital risk-standardized mortality and readmissions using random-effects logistic regression, before and after including early DNR status, to examine changes in overall model fit and hospital outlier designations. We included 109 521 patients from 289 hospitals and found that 8.5% (9356) patients had early DNR. Early DNR use varied widely, with median (interquartile range) hospital rates of 7.9% (4.1%-14.0%). Including early DNR in models used to assess hospital quality resulted in improvement in the mortality model (C statistics from 0.754 [0.748-0.759] to 0.784 [0.779-0.789]) but not the readmissions model. Of the hospitals designated high outliers for mortality and readmissions by the Centers for Medicare/Medicaid Services model, and therefore destined for a financial penalty, 6/25 (24%) were reclassified as nonoutliers for mortality and 2/14 (14.3%) for readmissions after including DNR status. Agreement in outlier status between the models before and after inclusion of early DNR status was moderate for mortality (κ, 0.603 [0.482-0.724]; P<0.001) and high for readmissions (κ, 0.888 [0.800-0.977]; P<0.001). Conclusions Including early DNR status in risk-adjustment models significantly improved model fit and resulted in substantial reclassification of hospital performance rankings for mortality and moderate reclassification for readmissions. DNR status at hospital admission should be considered when reporting risk-standardized hospital mortality.

Does advance care planning in addition to usual care reduce hospitalisation for patients with advanced heart failure: A systematic review and narrative synthesis

BACKGROUND

People with advanced heart failure have repeated hospital admissions. Advance care planning can support patient preferences, but studies in people with heart failure have not been assessed.

AIM

To evaluate the literature regarding advance care planning in heart failure.

DESIGN

Systematic review and narrative analysis (PROSPERO CRD42017059190).

DATA SOURCES

Electronic databases were searched (1990 to 23 March 2017): MEDLINE(R), Cochrane Library, CINAHL and Scopus. Four journals were hand searched. Two independent researchers screened against eligibility criteria. One reviewer extracted all data and a sample by a second. Quality was assessed by Cochrane Risk of Bias or the Critical Appraisal Skills Programme Tool for Cohort Studies.

RESULTS

Out of the 1713 articles, 8 were included representing 14,357 participants from in/outpatient settings from five countries. Two randomised controlled trials and one observational study assessed planning as part of a specialist palliative care intervention; one randomised controlled trial assessed planning in addition to usual cardiology care; one randomised controlled trial and one observational study assessed planning in an integrated cardiology-palliative care model; one observational study assessed evidence of planning (advance directive) as part of usual care and one observational study was a secondary analysis of trial participants coded Do Not Attempt Cardiopulmonary Resuscitation. Advance care planning: (1) reduced hospitalisation (5/7 studies); (2) increased referral/use of palliative services (4/4 studies); and (3) supported deaths in the patient-preferred place (2/2 studies).

CONCLUSION

Advance care planning as part of specialist palliative care reduces hospitalisation. Preliminary studies of planning integrated into generic care, accessing specialist palliative care support if needed, are promising.

Variation in Do-Not-Resuscitate Orders and Implications for Heart Failure Risk-Adjusted Hospital Mortality Metrics

OBJECTIVES

This study evaluated the effect of patient do-not-resuscitate (DNR) status on hospital risk-adjusted heart failure mortality metrics.

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Getting (Along) With the Guidelines: Reconciling Patient Autonomy and Quality Improvement Through Shared Decision Making

In past decades, stark differences in practice pattern, cost, and outcomes of care across regions with similar health demographics have prompted calls for reform. As health systems answer the growing call for accountability in the form of quality indices, while responding to increased scrutiny on practice variation in the form of pay for performance (P4P), a rift is widening between the system and individual patients. Currently, three areas are inadequately considered by P4P structures based largely on physician adherence to guidelines: diversity of patient values and preferences; time and financial burden of therapy in the context of multimorbidity; and narrow focus on quantitative measures that distract clinicians from providing optimal care. As health care reform efforts place greater emphasis on value-for-money of care delivered, they provide an opportunity to consider the other "value"-the values of each patient and care delivery that aligns with them.The inherent balance of risks and benefits in every treatment, especially those involving chronic conditions, calls for engagement of patients in decision-making processes, recognizing the diversity of preferences at the individual level. Shared decision making (SDM) is an attractive option and should be an essential component of quality health care rather than its adjunct. Four interwoven steps toward the meaningful implementation of SDM in clinical practice-embedding SDM as a health care quality measure, "real-world" evaluation of SDM effectiveness, pursuit of an SDM-favorable health system, and patient-centered medical education-are proposed to bring focus back to the beneficiary of health care accountability, the patient.

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

BACKGROUND

Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described.

METHODS

We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728).

RESULTS

Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina.

CONCLUSIONS

There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.