Code Status Documentation and Its Impact on In-Hospital Mortality in Colorectal Cancer Patients: A National Perspective

Abstract

Introduction: Colorectal cancer is a major contributor of morbidity and mortality in the U.S. accounting for 8% of all cancer deaths. The impact of code status on mortality in colorectal cancer patients has never been documented. We aim to determine the impact of code status on mortality in patients with colorectal cancer. Methods: We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database of 2010 - 2011 for colorectal cancer as a principal diagnosis using ICD 9-CM codes (153 and 154). NIS represents 20% of all US hospital patients and weighted numbers represent national estimates. We defined patients' DNR status with ICD-9 code V49.86. Our primary outcome of interest was in-hospital mortality. We utilized chi-square test for univariate analysis of categorical variables and generated hierarchical multilevel regression models to determine independent predictors of mortality. Results: We analyzed a total of 56972 patients (weighted n= 278866) with principal diagnosis of colorectal cancer out of which 1114 (weighted n= 5360) patients had DNR status. The proportion of in-hospital mortality (13.94% vs. 1.49%, p < 0.001) was higher in patients with DNR orders. Even after adjusting for confounders (demographics, co-morbidities, admission type, hospital region, and hospital teaching status), DNR status was associated with higher in-hospital mortality (OR 7.12, 95% CI, 6.57 to 7.72, p < 0.001) and adverse outcomes (OR 1.06, 95% CI, 1.04 to 1.08, p < 0.001). Conclusion: DNR status in patients admitted with colorectal cancer appears to be an independent and significant predictor of substantially increased hospital mortality. The reasons for such an outcome are multi-factorial and can be attributed to advanced disease stage, other co morbidities not accounted in NIS and hospital & physician factors. Further studies, involving both quantitative/qualitative aspects, are warranted to investigate these factors in detail.Figure 1