State variation in nursing home mortality outcomes according to do-not- resuscitate status

Background. This study compares mortality outcomes of Medicaid- reimbursed nursing home residents with and without do-not-resuscitate (DNR) orders in two diverse states. Methods. We used 1994 Minimum Data Set Plus (MDS+) information on 3215 nursing home residents from two states. We used Kaplan-Meier analyses to examine unadjusted mortality among those with and without DNR orders across states. We used a proportional hazard regression with main and interaction variables to model the likelihood of survival in the nursing home. Results. Approximately 27% of nursing home residents with DNR orders in State A die within the year, and approximately 40% of nursing home residents with DNR orders in State B die within the year. Regression results indicate that neither having a DNR order nor state of residence were independently associated with mortality. However, residing in State B and having a DNR order was associated with an increased risk of mortality compared with all others in the sample (risk ratio = 1.73; 95% confidence interval = 1.09, 2.75). Conclusion. This study demonstrates that DNR orders are associated with varying mortality across states. Future research is needed to identify the reasons why state level differences exist.