title: Association of Early Do-Not-Resuscitate Orders with Unplanned Readmissions among Patients Hospitalized for Pneumonia.
abstract: BACKGROUND
  In the United States, approximately 20% of patients hospitalized with pneumonia are readmitted to a hospital within 30 days. Given the significant costs and healthcare system use resulting from unplanned readmissions, pneumonia readmission rates are a target of national quality measures. Patient do-not-resuscitate (DNR) status strongly influences hospital pneumonia mortality measures; however, associations between DNR status and 30-day readmissions after pneumonia are unclear.
  
  
  OBJECTIVE
  Determine the effect of accounting for patient DNR status on hospital readmission measures for pneumonia.
  
  
  METHODS
  After excluding patients with missing data, those who died during the index hospitalization, those who were discharged against medical advice, those who did not reside in California, and those admitted to low pneumonia case-volume hospitals, we identified 30-day unplanned readmissions after an index pneumonia hospitalization from the 2011 California State Inpatient Database. We used hierarchical logistic regression to determine the association between early DNR status (within 24 hours of admission) and 30-day readmission and hospital risk-adjusted readmission rates.
  
  
  RESULTS
  We identified 68,691 hospitalizations for pneumonia across 321 hospitals. Patients with early DNR orders were less likely to be readmitted within 30 days (20.0% vs. 22.5%, adjusted odds ratio [aOR], 0.93; 95% confidence interval [CI], 0.88-0.99). Patients with pneumonia admitted to high-versus-low DNR rate hospitals were at lower risk for readmission (DNR rate quartile 4 vs. quartile 1, aOR, 0.62; 95% CI, 0.55-0.70), regardless of individual DNR status. Higher hospital risk-adjusted DNR rates were strongly associated with lower risk-adjusted readmission rates (r = -0.44; P < 0.0001). Inclusion of early DNR status in risk-adjusted readmission models changed ranking categories for 7/321 (2.2%) hospitals, with 2 hospitals no longer labeled as "under-performing outliers."
  
  
  CONCLUSIONS
  Patients with an early DNR order have a lower risk for readmission after a pneumonia hospitalization. Unmeasured DNR status weakly confounds hospital readmission measures; accounting for patient DNR status would alter readmission ratings for a small number of hospitals.
authors.affiliation: 1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado.
authors.forename: Anuj B
authors.initials: AB
authors.lastname: Mehta
authors.affiliation: 2 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan.|3 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
authors.forename: Colin R
authors.initials: CR
authors.lastname: Cooke
authors.affiliation: 4 Division of Pulmonary and Critical Care Medicine, Denver Health, Denver, Colorado.|5 Division of Pulmonary and Critical Care Medicine, University of Colorado Anschutz Campus, Aurora, Colorado.
authors.forename: Ivor S
authors.initials: IS
authors.lastname: Douglas
authors.affiliation: 6 Center for Quality of Care Research, Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts.|7 Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
authors.affiliation: 8 The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, and.|9 Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, Massachusetts.
authors.forename: Renda Soylemez
authors.initials: RS
authors.lastname: Wiener
authors.affiliation: 8 The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, and.|10 Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; and.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Walkey
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D016017:Odds Ratio; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000628:therapy*; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D011787:Quality of Health Care; D016414:Resuscitation Orders; D014479:United Arab Emirates; D014481:United States
keywords: access; advance directives; and evaluation; health care quality; health care quality indicators