title: Terminal hospitalizations of nursing home residents: does facility increasing the rate of do not resuscitate orders reduce them?
abstract: BACKGROUND
  Terminal hospitalizations are costly and often avoidable with appropriate advance care planning.
  
  
  OBJECTIVE
  This study examined the association between advance care planning, as measured by facility rate of do not resuscitate (DNR) orders in U.S. nursing homes (NHs) and changes in terminal hospitalization rates.
  
  
  METHODS
  Retrospective cohort study of the changing prevalence of DNR orders in U.S. NHs. Using a fixed effect multivariate model, we examined whether increasing facility rate of DNR orders correlates with reductions in terminal hospitalizations in the last week of life, controlling for changes in facility characteristics (staffing, use of NP/PA, case mix of nursing residents, admission volume, racial composition, payer mix).
  
  
  RESULTS
  The average facility rate of terminal hospitalizations was 15.5%, fluctuating between 1999 (15.0%) and 2007 (14.8%). NHs starting with low rates of DNR orders that increased their rates had fewer terminal hospital admissions in 2007 (11.2%) than facilities with continuously low DNR usage. Even after applying a multivariate fixed effect model, the effect of changes in facility DNR order rate on terminal hospitalization was -0.056 (95% confidence interval: -0.061, -0.050), indicating that for every 10% increase in DNR orders there was 0.56% decrease in terminal hospitalizations. This rate can be compared with the increase of 0.70% in the terminal hospitalization rate when an NH became disproportionately dependent on Medicaid funding or the 0.40% decrease in terminal hospitalization rate associated with adding a nurse practitioner to the clinical staff complement.
  
  
  CONCLUSIONS
  NHs that changed their culture of decision making by increasing their facility rate of DNR orders decreased their rate of terminal hospitalizations.
authors.affiliation: The Warren Albert Medical School of Brown University, Providence, Rhode Island, RI 02912, USA. Joan_Teno@brown.edu
authors.forename: Joan M
authors.initials: JM
authors.lastname: Teno
authors.forename: Pedro
authors.initials: P
authors.lastname: Gozalo
authors.forename: Susan L
authors.initials: SL
authors.lastname: Mitchell
authors.forename: Julie P W
authors.initials: JP
authors.lastname: Bynum
authors.forename: David
authors.initials: D
authors.lastname: Dosa
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009735:Nursing Homes / Q000706:statistics & numerical data*; D016414:Resuscitation Orders; D013727:Terminal Care / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology