{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:18:52Z","timestamp":1789496332099,"version":"build-2803163510"},"reference-count":16,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Population Health and Outcomes"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND:<\/jats:title>\n                    <jats:p>Publicly reported 30-day acute myocardial infarction (AMI) mortality rates are widely used to benchmark hospital performance. However, these measures may lack validity when they include deaths among patients with do-not-resuscitate (DNR) orders or those receiving palliative care\u2014groups for whom mortality may be expected and goal-concordant.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                    <jats:p>We analyzed the national 100% Medicare Inpatient Standard Analytic File and Medicare Beneficiary Summary file to assess 30-day AMI mortality rates stratified by DNR status (absent, present-on-admission, and postadmission) and palliative care involvement. We then conducted a retrospective chart review of all 30-day AMI mortalities at a single academic medical center (2019\u20132025), applying Global Registry of Acute Coronary Events and a Palliative Performance Scale scores to identify unpreventable deaths, which we defined as a Global Registry of Acute Coronary Events &gt;190.5 or Palliative Performance Scale \u226440%. Global Registry of Acute Coronary Events is a risk-stratification tool using clinical and laboratory variables whereas the Palliative Performance Scale is a bedside functional status and palliative care assessment quantifying patient\u2019s self-care ability.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>Across n=467\u2009259 total AMI encounters, mean (SD) age was 75.1 (10.5), and the population was 44% women. Thirty-day mortality was 10.4% (39\u2009112\/376\u2009062) among patients without DNRs, 43.1% (26\u2009181\/60\u2009719) in those with present-on-admission DNR, and 72.1% (21\u2009984\/30\u2009478) in those with postadmission DNR. Among 9.2% (43\u2009090\/467\u2009259) of encounters with palliative care, there was a 76.9% mortality rate (33\u2009151\/43\u2009090). Hazard ratios for mortality were 5.25 (95% CI, 5.17\u20135.33) for present-on-admission DNR and 10.73 (95% CI, 10.55\u201310.91) for postadmission DNR as compared with encounters without DNRs. Among n=24 AMI mortalities at our institution, 71% (17\/24) had DNRs, and 33% (8\/24) met the unpreventable death criteria.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>The validity of 30-day AMI mortality metrics may be undermined by their inclusion of high-acuity, end-of-life patients, which may disincentivize hospitals from delivering appropriate, patient-centered care. Removal of DNR or palliative cases from performance measures should be explored to better identify opportunities for reducing preventable deaths.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circoutcomes.125.013117","type":"journal-article","created":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T09:00:15Z","timestamp":1785402015000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["DNR Status and Hospital Mortality Measures Postmyocardial Infarction: Differentiating Preventable From Unpreventable Deaths in CMS Data"],"prefix":"10.1161","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4544-3158","authenticated-orcid":true,"given":"Benjamin D.","family":"Pollock","sequence":"first","affiliation":[{"name":"Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL (B.D.P.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-1659-8855","authenticated-orcid":true,"given":"Annette M.","family":"Danks","sequence":"additional","affiliation":[{"name":"Department of Clinical Documentation Integrity (A.M.D.), Mayo Clinic, Rochester, MN."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1914-5985","authenticated-orcid":true,"given":"Razvan M.","family":"Chirila","sequence":"additional","affiliation":[{"name":"Department of General Internal Medicine (R.M.C.), Mayo Clinic, Jacksonville, FL."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9146-5599","authenticated-orcid":true,"given":"Pablo","family":"Moreno Franco","sequence":"additional","affiliation":[{"name":"Department of Critical Care Medicine (P.M.F.), Mayo Clinic, Jacksonville, FL."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7583-3355","authenticated-orcid":true,"given":"Jordan C.","family":"Ray","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville (J.C.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2092-7551","authenticated-orcid":true,"given":"Sean C.","family":"Dowdy","sequence":"additional","affiliation":[{"name":"Department of Quality and Value (S.C.D.), Mayo Clinic, Rochester, MN."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7127-7432","authenticated-orcid":true,"given":"Jennifer B.","family":"Cowart","sequence":"additional","affiliation":[{"name":"Department of Hospital Internal Medicine (J.B.C.), Mayo Clinic, Rochester, MN."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.108.804880"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.10383"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamainternmed.2015.6324"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.7314"},{"key":"e_1_3_3_6_2","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.121.021061"},{"key":"e_1_3_3_7_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.1938"},{"key":"e_1_3_3_8_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.118.005196"},{"key":"e_1_3_3_9_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.287.24.3206"},{"key":"e_1_3_3_10_2","unstructured":"2025 AMI Mortality Measure Specifications \u2013 Supplemental File. CMS. Accessed August 14 2025. https:\/\/qualitynet.cms.gov\/inpatient\/measures\/mortality\/methodology"},{"key":"e_1_3_3_11_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2024.20472"},{"key":"e_1_3_3_12_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2013-004425"},{"key":"e_1_3_3_13_2","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehy517"},{"key":"e_1_3_3_14_2","doi-asserted-by":"publisher","DOI":"10.1186\/s43044-021-00146-9"},{"key":"e_1_3_3_15_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2023.0024"},{"key":"e_1_3_3_16_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp2215539"},{"key":"e_1_3_3_17_2","doi-asserted-by":"publisher","DOI":"10.1093\/ehjacc\/zuaf014"}],"container-title":["Circulation: Population Health and Outcomes"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/CIRCOUTCOMES.125.013117","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:01:09Z","timestamp":1789495269000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ahajournals.org\/doi\/10.1161\/CIRCOUTCOMES.125.013117"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9]]},"references-count":16,"journal-issue":{"issue":"9","published-print":{"date-parts":[[2026,9]]}},"alternative-id":["10.1161\/CIRCOUTCOMES.125.013117"],"URL":"https:\/\/doi.org\/10.1161\/circoutcomes.125.013117","relation":{},"ISSN":["3068-563X"],"issn-type":[{"value":"3068-563X","type":"print"}],"subject":[],"published":{"date-parts":[[2026,9]]},"assertion":[{"value":"2025-11-13","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-21","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-30","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}