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Quality of Care/Hospital Systems

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Researchers examine implications of early use of DNR orders for critically ill ICU patients

Most do-not-resuscitate (DNR) orders issued in the intensive care unit (ICU) are for older, more severely ill patients and are issued after the patient has been in the ICU for a day or more. Some DNRs, however, are issued during the patient's first day in the ICU. A new study shows that about 36 to 38 percent of patients with DNRs at ICU admission died in the ICU, and 65 to 67 percent died in the hospital. More than 50 percent of those who received DNRs later in their ICU stay died in the ICU, and more than 80 percent died in the hospital. The overall percentage of patients with very long ICU stays (more than 30 days) and hospital stays (more than 60 days) was smaller among DNR patients.

These shorter stays by ICU patients with DNR orders suggest that patients who would have died in the hospital anyway did so after a shorter time period. Their medical outcomes were the same, but use of high-technology medical resources was lower, explains John Rapoport, Ph.D., of the University of Massachusetts.

In a study supported in part by the Agency for Health Care Policy and Research (HS06026), he and coinvestigators used a detailed database of ICU patients from six ICUs in four U.S. hospitals to examine conditions under which DNR orders were issued and their influence on subsequent length of stay.

The decision to limit care for critically ill ICU patients is not uncommon, and most deaths in the ICU are now preceded by DNR orders, which are regarded by some as a way to make death more humane and respect patient autonomy. This study contradicts the view of some critics that the "do everything" approach until the very end is standard practice in the United States for critically ill patients. More than half of the patients who died did so after care had been limited, concludes Dr. Rapoport.

See "Resource use implications of do not resuscitate orders for intensive care unit patients," by Dr. Rapoport, Daniel Teres, M.D., and Stanley Lemeshow, Ph.D., in the American Journal of Respiratory and Critical Care Medicine 153, pp. 185-190, 1996.

Nearly one-quarter of ICU patients with chronic obstructive pulmonary disease die in the hospital

Chronic obstructive pulmonary disease (COPD) is the fifth most common cause of death in the United States and is becoming more prevalent, especially among women. COPD patients frequently are admitted to an intensive care unit (ICU) because of increased respiratory compromise without an objectively documented cause such as pneumonia. Twenty-four percent of these ICU patients die in the hospital, according to a study supported in part by the Agency for Health Care Policy and Research (HS07137).

For elderly COPD patients (65 years of age or older) discharged from the hospital, mortality doubles from 30 percent at discharge to 59 percent 1 year later. The major risk factor for both hospital mortality and subsequent death is the development and severity of nonrespiratory organ system dysfunction. The need for mechanical ventilation at ICU admission is not a significant predictor of either short- or long-term outcomes, once other patient risk factors are considered, notes Michael G. Seneff, M.D., from the ICU Research Unit at the George Washington University, who led the study.

The researchers analyzed hospital mortality and 90-day, 180-day, and 1-year postdischarge mortality for 362 ICU patients admitted to 42 ICUs with acute exacerbation of COPD. In most cases, the acute life-threatening components of these exacerbations can be reversed and short-term death avoided by mechanical ventilation and other appropriate treatments. However, patients with greater abnormalities in respiratory system physiology (which reflect underlying severity of lung disease) who survive hospitalization are at higher risk of subsequent death.

Details are in "Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease," by Dr. Seneff, Douglas P. Wagner, Ph.D., Randall P. Wagner, M.D., and others, in the December 20, 1995 Journal of the American Medical Association 274(23), pp. 1852-1857.

Changes in reimbursement policies more than changes in technology have altered the mix of inpatient procedures

During the 1980s, development of new technologies, pressure from reimbursement mechanisms, and utilization review policies all contributed to a decline in inpatient use of certain procedures. Of the 150 most frequent inpatient procedures in 1980, 37 had declined in use by more than 40 percent as of 1987. In 1980, these 37 procedures accounted for about 17 percent of all inpatient principal procedures performed; in 1987 they accounted for only 5 percent. These are the findings of a study by Sarah Q. Duffy, Ph.D., of the Maryland State Health Services Cost Review Commission, and Dean E. Farley, Ph.D., M.P.A., of H.S.S., Inc., both formerly of the Agency for Health Care Policy and Research.

According to the researchers, three main factors contributed to the decline in inpatient use of these procedures. Most important has been the shift from inpatient to outpatient settings, which pertains to 33 of the 37 procedures covered in this study. Some procedures have been replaced by less invasive, more effective approaches, and others are now considered ineffective by the medical community and have been largely abandoned.

The rates of decline in inpatient procedures have been disproportionately large for Medicaid recipients. Medicaid patients may be unusually good candidates for outpatient treatment, note the researchers, because they tend to be younger and less severely ill. Also, Medicaid typically paid a smaller portion of actual costs for inpatient care in the 1980s (92 percent, compared with 95 to 101 percent for Medicare and well over 100 percent for most private insurers).

Finally, hospitalized patients were more severely ill in 1987 than in 1980. The overall mortality rate and proportion of patients with stage 3 or higher disease (characterized by multiple site and generalized systemic involvement and poor prognosis) increased almost 50 percent between 1980 and 1987 for the 37 procedures included in this study.

Hospitals are more efficient than they were in the 1970s, and they contain sicker, older patients needing costlier treatment than when many of these cost-containment policies were developed, note the researchers. They caution that continued squeezing to promote efficiency may have unforeseen effects on the care of inpatients and, ultimately, could begin to compromise clinical effectiveness.

The authors used data from AHCPR's Healthcare Cost and Utilization Project (HCUP-2) for this study. Details are in "Patterns of decline among inpatient procedures," by Drs. Duffy and Farley, in the November/December 1995 issue of Public Health Reports 110, pp. 674-681.

Over 8 percent of hospitalized Medicare patients arrive from nursing homes

A first-time national estimate shows that 8.5 percent of hospitalized elderly Medicare patients arrived at the hospital from nursing homes in 1987. In most cases, these hospitalizations were for persons who were permanent residents of nursing homes, according to Marc P. Freiman, Ph.D., of the Agency for Health Care Policy and Research's Center for Cost and Financing Studies, and former AHCPR researcher Christopher M. Murtaugh, Ph.D., now with the Medical Technology and Practice Patterns Institute.

They used data from the 1987 National Medical Expenditure Survey and 1987 Medicare hospital data to compare hospitalizations of nursing home patients with those of elderly persons living in the community. They found that elderly persons with some nursing home use were 2.5 times more likely to have at least one hospital stay during 1987 than persons who had not been in a nursing home that year. And, although they made up less than 7 percent of the total elderly population, nursing home residents in 1987 received nearly one-fourth (23.8 percent) of all the hospital care days provided to elderly persons in that year. Also, the average hospital stay for nursing home residents was 2 weeks, 56 percent longer than the 8.9-day average for elderly persons who had not used a nursing home in 1987.

For more information, see "Interactions between hospital and nursing home use," by Drs. Freiman and Murtaugh, published in the September/October 1995 Public Health Reports 110, pp. 546-554.

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