Sunday, August 31, 2008

The pneumonia deaths

A recent news report cited Community General Hospital for pneumonia death rates above the national average. The story was based on mortality statistics published by the Centers for Medicare and Medicaid Services (CMS). The mortality rates were mathematically adjusted for differences in patients' medical conditions, but the rates did not adjust for differences in mortality due to patients’ own do-not-resuscitate (“DNR”) orders.

The Post-Standard reported that for Medicare-covered pneumonia patients “the national mortality rate was 11.4 percent. Community General Hospital… had a pneumonia death rate above the national rate 15.1 percent.” In paragraph eight, the story appropriately quoted Fred Goldberg, MD, Community’s Chief Medical Officer, explaining that “these report cards do not account for...end-of-life preferences."

The distinction may be too subtle for headline writers.

Last year I wrote about CMS’ plans to add pneumonia mortality rates to its Hospital Compare website. I discussed Community’s past investigations into pneumonia deaths with respect to patients’ DNR orders – and I quoted “Mortality as a Measure of Quality: Implications for Palliative and End-of-Life Care” from the Journal of the American Medical Association (JAMA):
Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.
Following the recent news story, I again looked up the JAMA article. It said:
Treatments provided to seriously ill patients are often inconsistent with patients' underlying preferences….[T]here is a 10-fold variation in the rates of early do-not-resuscitate (DNR) orders across hospitals and dramatic variation in the proportion of all intensive care unit deaths preceded by withdrawal of life support….Such decisions may be relatively more common in the 600,000 hospital deaths that occur each year (over 50% of all hospital deaths) in patients aged 75 years or older who are at increased risk for accumulating multiple chronic illnesses.
During the period of time reported in the CMS data, the average age of the pneumonia patients who died at Community General was 83. As Dr. Goldberg reported, 93% of them had do-not-resuscitate orders.

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