Pneumonia As Hospital Quality Indicator May Lead To Overly Aggressive Care

Mihaela S Stefan, MD FACP Research Scientist, Center for Quality of Care Research Director of Outpatient Perioperative Clinic and Medical Consultation Program Academic Hospitalist Baystate Medical Center Assistant Professor of Medicine, Tufts University School of Medicine Springfield MA 01199MedicalResearch.com Interview with:
Mihaela S Stefan, MD FACP
Research Scientist, Center for Quality of Care Research
Director of Outpatient Perioperative Clinic and
Medical Consultation Program
Academic Hospitalist Baystate Medical Center
Assistant Professor of Medicine, Tufts University School of Medicine
Springfield MA 01199

MedicalResearch: What is the background for this study?

Dr. Stefan : Mortality rates for patients with pneumonia are publicly reported and are used to evaluate hospital performance. The rates are calculated using Medicare administrative claims data which provide limited insight into severity of illness and comorbidities that may be associated with death. The mortality measure does not take into consideration advance directives or changes in goals of care preferences during hospitalization.

MedicalResearch: What are the main findings?

Dr. Stefan : In this retrospective chart review of 202 adults who died with a principal diagnosis of pneumonia between January 2008 and December 2012 in 3 hospitals in MA, we assessed the proportion of patients for whom pneumonia was determined to play a major or a minor role in the patient death. Pneumonia was considered a minor cause if the patient had advanced life threatening illnesses and this was found in 82% of the deaths. More than half of the patients were DNR at admission to the hospital. The majority of patients who died were frail elderly with life-threatening conditions who decided to forgo aggressive care at some point during their admission. Only a small fraction of deaths in the pneumonia mortality measure were the direct result of pneumonia.

MedicalResearch: What should clinicians and patients take away from your report?

Dr. Stefan : For patients with advanced life-threatening illnesses who decided to forgo life supporting treatment, the quality of pneumonia care delivered by the hospital may not have an impact on prolonging life. In fact, initiation of palliative care for these patients should be considered providing high quality care. Counting such deaths as a marker of poor quality care may create incentives for hospitals to provide the most aggressive care for everyone, regardless of whether such care is appropriate or in keeping with patient preferences.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Dr. Stefan : Based on the prior evidence and our study the mortality rates should at least be adjusted for the patient’s health status prior to admission and the proportion of patients with advanced directives against aggressive care at admission or shortly thereafter. In this way, mortality rate will report acute deaths rather than including end-of life care.

Citation:

Stefan MS, Jaber R, Lindenauer PK, Garb JL, Fitzgerald J, Rothberg MB. Death Among Patients Hospitalized With Pneumonia: Implications for Hospital Outcome Measures. JAMA Intern Med. Published online March 16, 2015. doi:10.1001/jamainternmed.2015.114.

MedicalResearch.com Interview with: Mihaela S Stefan, MD FA (2015). Pneumonia As Hospital Quality Indicator May Lead To Overly Aggressive Care MedicalResearch.com