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

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.Determine the effect of accounting for patient DNR status on hospital readmission measures for pneumonia.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.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."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.