Current efforts to grade the quality of care hospitals provide stroke patients have a big flaw according to a new study in the journal Stroke. Measures of mortality – whether or not a stroke patient dies shortly after being admitted to a hospital – do not take into account whether these deaths occurred because of poor care or because physicians were carrying out the wishes of the patient and their family to withhold care.
At issue is the use of do-not-resuscitate (DNR) orders which are often put in place after severe strokes when the prognosis is severe disability. These orders are intended to place limits heroic, life-extending care.
The study, led by UR Medicine neurologist Adam Kelly, M.D., looked at stroke data over a 6-year period for 355 hospitals in California. They discovered that there was a wide variation in the use of DNRs – which are most commonly put in place after a stroke patient is admitted – with a ten-fold difference between the hospitals with the lowest and highest DNR rates.
The problem is that it is not entirely clear what the “right” rate of DNR use should be. Used correctly, the orders are an essential tool of patient- and family-centered care. However, some physicians may be too quick to limit interventions, while others may advocate for care that will not change outcomes and may only prolong suffering. These variations could be the result of difference in an institution’s philosophy of care, the preference of individual providers, or regional factors.
The researchers tried to create a level playing field by projected what mortality would look like – based on the known risk factors of the patients – without the use of DNRs. The result was that there were big swings in where individual hospitals “ranked” in terms of their quality of care, with some poor performers becoming average and vice versa.
You can read more about the study here.