OUTCOMES OF INSTABILITY ON DISCHARGE IN URBAN HOSPITALS

20世纪80年代引入的医疗保险预期支付 导致住院时间缩短， 患者在达到医学稳定之前出院，以及 出院后死亡的风险更大。 这被称为 更快更病态的现象 管理式护理的增长 在过去的10年里， 留下来。 我们建议制定通用和针对具体情况的措施 出院时不稳定，并检查其患病率和相关 在1990年代的城市医院里。 我们的建议侧重于 肺炎、髋骨骨折和哮喘，因为它们很常见， 具有显著发病率和死亡率的病症。 我们的目标是城市 医院，因为内城人口（穷人，少数民族，没有保险， 和老年人）特别容易受到早期 放电 在纽约，还有一个相对的问题， 不发达，医院后的安全网扩大的初级和 亚急性护理服务。 我们提出了一项观察性的多队列研究， 出院及其相关风险调整后的住院后结局 （死亡率、再入院率、功能状态、症状缓解率和 患者满意度）。 这种做法的可行性和可承受性 建议是通过我们使用2个现有的数据库的帮助。 对于肺炎， 我们将使用AHCPR资助的肺炎患者结局研究小组 数据库，一项前瞻性研究，来自3个国家4家医院的686名住院患者 城市 对于髋部骨折，我们将补充AHCPR资助的 髋关节骨折研究，一项在4个纽约州600名患者中进行的前瞻性研究 西奈山卫生系统的医院 对于哮喘，我们建议 前瞻性、观察性队列研究，纳入了500名患有 哮喘到西奈山医疗中心，纽约超过1年。 所有数据库 将有基线患者数据、出院时的稳定性、出院 位置和30天的结果。 我们的分析将评估：1）出院时的不稳定率; 2） 出院时不稳定性与出院后结局之间的关系 在调整基线患者特征，疾病严重程度， 合并症和功能状态; 3）通用的预测有效性 与特定条件下的不稳定措施;和4）的影响 出院后的位置对这些风险调整的结果。 我们将 第一年进行肺炎研究，第二年进行髋部骨折研究 第三年，哮喘。 这项工作的最终成果将 是一套通用和针对具体情况的可操作措施， 出院时的不稳定性，可作为 住院病人护理质量。

The introduction of prospective payment for Medicare in the 1980s resulted in shorter hospital length of stay, higher proportions of patients being discharged prior to reaching medical stability, and greater risks of post-discharge death. This has been called the quicker and sicker phenomenon. The growth of managed care over the past 10 years has brought about even more dramatic declines in length of stay. We propose to develop generic and condition-specific measures of instability on discharge, and examine its prevalence and associated consequences in urban hospitals during the 1990s. Our proposal focuses on pneumonia, hip fracture and asthma because they are common, costly conditions with significant morbidity and mortality. We target urban hospitals because inner city populations (poor, minorities, uninsured, and elderly) are especially vulnerable to the consequences of early discharge. In NY, there is the additional problem of a relatively underdeveloped, post-hospital safety net of expanded primary and subacute care services. We propose an observational, multiple cohort study of instability on discharge and its associated risk-adjusted post-hospital outcomes (mortality, readmission, functional status, symptom resolution, and patient satisfaction). The feasibility and affordability of this proposal is aided by our use of 2 existing databases. For pneumonia, we will use the AHCPR-funded Pneumonia Patient Outcomes Research Team database, a prospective study of 686 inpatients from 4 hospitals in 3 cities. For hip fracture, we will supplement data from the AHCPR-funded Hip Fracture Study, a prospective study of 600 patients in 4 NY hospitals in the Mount Sinai Health System. For asthma, we propose a prospective, observational cohort study of 500 adults admitted with asthma to the Mount Sinai Medical Center, NY over 1 year. All databases will have baseline patient data, stability on discharge, discharge location, and 30 day outcomes. Our analyses will assess: 1) rates of instability on discharge; 2) associations between instability on discharge and post-hospital outcomes after adjusting for baseline patient characteristics, disease severity, comorbidities, and functional status; 3) predictive validity of generic versus condition-specific measures of instability; and 4) effects of post-discharge location on these risk-adjusted outcomes. We will perform the study of pneumonia in the 1st year, hip fracture in the 2nd year, and asthma in the 3rd year. The final product of this work will be an operational set of generic and condition-specific measures of instability on discharge that can serve as evidence-based indicators of inpatient quality of care.