• Finlay A McAlister, Julie Wang, Linda Donovan, Douglas S Lee, Paul W Armstrong, and Jack V Tu.
• From the Division of General Internal Medicine (F.A.M.) and Canadian VIGOUR Centre (F.A.M., P.W.A.), Department of Medicine, University of Alberta, Edmonton, Canada; Institute for Clinical Evaluative Sciences (J.W., D.S.L., J.V.T.) and Division of Cardiology, Department of Medicine, Sunnybrook Schulich Heart Centre (L.D., J.V.T.), University of Toronto, Canada; and Peter Munk Cardiac Centre, Division of Cardiology, and Joint Department of Medical Imaging, University Health Network, Toronto, Canada (D.S.L.). Finlay.McAlister@ualberta.ca.
• Circ Heart Fail. 2015 May 1; 8 (3): 481-8.

BackgroundPay for performance programs compare metrics that are risk-adjusted, but goals of care are not considered in current models. We conducted this study to explore the associations between do not resuscitate (DNR) designations, quality of care, and outcomes.Methods And ResultsRetrospective cohort study with chart review for inpatient quality metrics, 30 day mortality, and readmissions or death within 30 days of discharge in 96 Ontario hospitals participating in the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) study in 2004/05. Of 8339 patients (mean age 77 years) with new heart failure, 1220 (15%) had DNR documented at admission (admission DNR, varying from 0% to 36% between hospitals) and 892 (11%) were switched from full resuscitation to DNR during their index hospitalization (later DNR). Death at 30 days was more common in patients with admission DNR (27%) or later DNR (35%) than full resuscitation (3%)-admission DNR was a stronger predictor (adjusted OR 8.6, 95% confidence interval 6.8-10.7) than any of the variables currently included in heart failure 30 day mortality risk models. Hospital-level rankings differed considerably if DNR patients were excluded: 22 of the 39 EFFECT hospitals in the top and bottom quintiles for 30 day mortality rates (the usual thresholds for rewards/penalties in current performance-based reimbursement schemes) would not have been in those same quintiles if admission DNR patients were excluded.ConclusionsAlternate goals of care are frequent and important confounders in heart failure comparative studies. Philosophy of care discussions should be considered for inclusion as a potential quality of care indicator.© 2015 American Heart Association, Inc.

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