Association of Early Do-Not-Resuscitate Orders with Unplanned Readmissions among Patients Hospitalized for Pneumonia

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Rationale: 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. Objectives: 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. Measurements and Main 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.

Related collections

Most cited references 14

Record: found
Abstract: found
Article: not found

Racial and ethnic differences in preferences for end-of-life treatment.

Amber E. Barnato, Denise Anthony, Jonathan Skinner … (2009)

Studies using local samples suggest that racial minorities anticipate a greater preference for life-sustaining treatment when faced with a terminal illness. These studies are limited by size, representation, and insufficient exploration of sociocultural covariables. To explore racial and ethnic differences in concerns and preferences for medical treatment at the end of life in a national sample, adjusting for sociocultural covariables. Dual-language (English/Spanish), mixed-mode (telephone/mail) survey. A total of 2,847 of 4,610 eligible community-dwelling Medicare beneficiaries age 65 or older on July 1, 2003 (62% response). Demographics, education, financial strain, health status, social networks, perceptions of health-care access, quality, and the effectiveness of mechanical ventilation (MV), and concerns and preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. Respondents included 85% non-Hispanic whites, 4.6% Hispanics, 6.3% blacks, and 4.2% "other" race/ethnicity. More blacks (18%) and Hispanics (15%) than whites (8%) want to die in the hospital; more blacks (28%) and Hispanics (21.2%) than whites (15%) want life-prolonging drugs that make them feel worse all the time; fewer blacks (49%) and Hispanics (57%) than whites (74%) want potentially life-shortening palliative drugs, and more blacks (24%, 36%) and Hispanics (22%, 29%) than whites (13%, 21%) want MV for life extension of 1 week or 1 month, respectively. In multivariable analyses, sociodemographic variables, preference for specialists, and an overly optimistic belief in the effectiveness of MV explained some of the greater preferences for life-sustaining drugs and mechanical ventilation among non-whites. Black race remained an independent predictor of concern about receiving too much treatment [adjusted OR = 2.0 (1.5-2.7)], preference for dying in a hospital [AOR = 2.3 (1.6-3.2)], receiving life-prolonging drugs [1.9 (1.4-2.6)], MV for 1 week [2.3 (1.6-3.3)] or 1 month's [2.1 (1.6-2.9)] life extension, and a preference not to take potentially life-shortening palliative drugs [0.4 (0.3-0.5)]. Hispanic ethnicity remained an independent predictor of preference for dying in the hospital [2.2 (1.3-4.0)] and against potentially life-shortening palliative drugs [0.5 (0.3-0.7)]. Greater preference for intensive treatment near the end of life among minority elders is not explained fully by confounding sociocultural variables. Still, most Medicare beneficiaries in all race/ethnic groups prefer not to die in the hospital, to receive life-prolonging drugs that make them feel worse all the time, or to receive MV.

0 comments Cited 97 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003-2009.

P S Pekow, Michael Rothberg, Tara Lagu … (2012)

Recent reports suggest that the mortality rate of patients hospitalized with pneumonia has steadily declined. While this may be the result of advances in clinical care or improvements in quality, it may also represent an artifact of changes in diagnostic coding. To compare estimates of trends in hospitalizations and inpatient mortality among patients with pneumonia using 2 approaches to case definition: one limited to patients with a principal diagnosis of pneumonia, and another that includes patients with a secondary diagnosis of pneumonia if the principal diagnosis is sepsis or respiratory failure. Trends study using data from the 2003-2009 releases of the Nationwide Inpatient Sample. Change in the annual hospitalization rate and change in inpatient mortality over time. From 2003 to 2009, the annual hospitalization rate for patients with a principal diagnosis of pneumonia declined 27.4%, from 5.5 to 4.0 per 1000, while the age- and sex-adjusted mortality decreased from 5.8% to 4.2% (absolute risk reduction [ARR], 1.6%; 95% CI, 1.4%-1.9%; relative risk reduction [RRR], 28.2%; 95% CI, 25.2%-31.2%). Over the same period, hospitalization rates of patients with a principal diagnosis of sepsis and a secondary diagnosis of pneumonia increased 177.6% from 0.4 to 1.1 per 1000, while inpatient mortality decreased from 25.1% to 22.2% (ARR, 3.0%; 95% CI, 1.6%-4.4%; RRR, 12%; 95% CI, 7.5%-16.1%); hospitalization rates for patients with a principal diagnosis of respiratory failure and a secondary diagnosis of pneumonia increased 9.3% from 0.44 to 0.48 per 1000 and mortality declined from 25.1% to 19.2% (ARR, 6.0%; 95% CI, 4.6%-7.3%; RRR, 23.7%; 95% CI, 19.7%-27.8%). However, when the 3 groups were combined, the hospitalization rate declined only 12.5%, from 6.3 to 5.6 per 1000, while the age- and sex-adjusted inpatient mortality rate increased from 8.3% to 8.8% (AR increase, 0.5%; 95% CI, 0.1%-0.9%; RR increase, 6.0%; 95% CI, 3.3%-8.8%). Over this same time frame, the age-, sex-, and comorbidity-adjusted mortality rate declined from 8.3% to 7.8% (ARR, 0.5%; 95% CI, 0.2%-0.9%; RRR, 6.3%; 95% CI, 3.8%-8.8%). From 2003 to 2009, hospitalization and inpatient mortality rates for patients with a principal diagnosis of pneumonia decreased substantially, whereas hospitalizations with a principal diagnosis of sepsis or respiratory failure accompanied by a secondary diagnosis of pneumonia increased and mortality declined. However, when the 3 pneumonia diagnoses were combined, the decline in the hospitalization rate was attenuated and inpatient mortality was little changed, suggesting an association of these results with temporal trends in diagnostic coding.

0 comments Cited 87 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

The relationship between hospital admission rates and rehospitalizations.

E. Orav, A Jha, Adrian Epstein (2011)

Efforts to reduce hospital readmissions have focused primarily on improving transitional care. Yet variation in readmission rates may more closely reflect variation in the underlying hospitalization rates than differences in the quality of care during and after discharge. We used national Medicare data to calculate, for each local hospital referral region (HRR), the 30-day, 60-day, and 90-day readmission rates among patients discharged with congestive heart failure or pneumonia. We also calculated population-based all-cause admission rates among Medicare enrollees in each HRR. We examined the variation in HRR readmission rates that was explained by overall hospitalization rates versus differences in patients' coexisting conditions, quality of discharge planning, physician supply, and bed supply. HRR readmission rates ranged from 11 to 32% for congestive heart failure and from 8 to 27% for pneumonia. In univariate analyses, all-cause admission rates accounted for the highest proportion of regional variation in readmission rates for congestive heart failure (28%, 34%, and 37% at 30, 60, and 90 days, respectively); the next highest proportions were explained by case mix (11%, 15%, and 18%) and the number of cardiologists per capita (12%, 14%, and 15%). Results for pneumonia were similar, except that the number of pulmonologists per capita accounted for a lower proportion of the variation (6%, 8%, and 7%, respectively). In multivariate analyses, admission rates accounted for 16 to 24% of the variation for congestive heart failure and 11 to 20% for pneumonia; no other factor accounted for more than 6%. We found a substantial association between regional rates of rehospitalization and overall admission rates. Programs directed at shared savings from lower utilization of hospital services might be more successful in reducing readmissions than programs initiated to date. (Funded by the Commonwealth Fund.).