OUTCOMES OF INSTABILITY ON DISCHARGE IN URBAN HOSPITALS

20世纪80年代医疗保险预付制的引入 导致住院时间更短，比例更高 患者在达到医疗稳定之前出院，以及 出院后死亡的风险更大。这被称为 更快、更虚弱的现象。管理型医疗保健的增长 在过去的10年里，长度的下降更加戏剧性 留下来。我们建议制定一般性和针对具体情况的措施 出院时的不稳定性，并检查其流行率和相关 20世纪90年代在城市医院的后果。我们的建议将重点放在 肺炎、髋部骨折和哮喘，因为它们很常见，费用也很高 有严重发病率和死亡率的情况。我们的目标是城市 医院，因为市中心的人口(穷人，少数民族，没有保险， 和老年人)特别容易受到过早 出院。在纽约，还有一个额外的问题，即相对 不发达的、医院后扩大的初级和初级保健安全网 亚急性护理服务。 我们提出了一项关于不稳定性的观察性多队列研究。 出院及其相关的风险调整后的院后转归 (死亡率、再入院、功能状态、症状缓解和 患者满意度)。这样做的可行性和可负担性 建议是由我们使用现有的2个数据库的帮助。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，对3月份4所医院的686名住院患者进行了前瞻性研究 城市。对于髋部骨折，我们将补充AHCPR资助的数据 髋部骨折研究：一项对4个纽约州600名患者的前瞻性研究 西奈山卫生系统的医院。对于哮喘，我们建议一种 对500名入院的成人进行前瞻性、观察性队列研究 哮喘到西奈山医疗中心，纽约州，超过1年。所有数据库 将有基线患者数据，出院、出院时的稳定性 地点和30天的结果。 我们的分析将评估：1)放电时的不稳定性；2) 出院时的不稳定性与院后转归的关系 在调整了基线患者特征、疾病严重程度、 共病和功能状态；3)仿制药的预测效度 与特定条件下的不稳定措施的对比；以及4) 出院后地点对这些风险调整结果的影响。我们会 第一年进行肺炎研究，第二年进行髋部骨折研究 3岁时哮喘。这项工作的最终产品将是 是一套可操作的通用和特定于条件的措施 出院时的不稳定性可作为循证指标 住院病人的护理质量。

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.