Testing biopsychosocial mechanisms of the posthospital syndrome model of early rehospitalization in acute coronary syndrome patients

 描述(由申请人提供)：医院环境是为治疗急性疾病而设计的，在过去的一个世纪里，基于财政、人口和政治压力，医院环境发生了无系统的演变。我们已经成为治疗急性心脏事件的专家，但新的证据表明，住院本身可能会削弱我们的患者--使他们在康复期间容易受到一系列疾病的影响。最近一项对500,000名心脏病患者的研究发现，每5名患者中就有1名在出院后30天内再次住院。令人惊讶的是，在这些再住院的患者中，只有一半是因为心脏原因。由于《平价医疗法案》中新的财务规定将报销与再住院率联系在一起，医院非常有动力减少这些早期再住院。 一种新的“后遗症”(PHS)模型表明，住院压力本身增加了再次住院的风险，因为它将患者置于普遍风险的短暂状态。测试这一模型，并确定将患者置于危险境地的医院环境和患者因素，对于指导医院努力减少30天的再次住院至关重要。这项拟议研究的第一个目标是测试PHS模型，以解释心脏病患者在出院后30天内因各种原因再次住院的高风险。第二个目标是确定对PHS有最大贡献的可改变的医院因素，并通过这样做来确定减少早期再次住院的目标。第三个目标是确定可能与PHS相关的患者因素，如个性和社会支持，以便我们最终能够进行风险分层，并改善患者成功过渡到独立的医院后护理。我们计划连续招募1000名通过急诊科(ED)入院的心脏病患者，跟踪他们的整个住院过程，并确定30天的再住院情况。我们将评估4个住院危险因素：使用生态瞬时评估(EMA)评估压力；通过活动记录仪评估睡眠和体力活动；通过电子秤评估体重减轻。我们还将客观地评估可能导致压力的医院因素：压力环境因素(急诊室拥挤程度和住院时间[LOS]；住院期间过度噪音和照明)。此外，我们将衡量可能影响住院体验的患者因素，包括个性、社会支持、心脏严重程度以及住院期间和之后的身体和精神并存。最后，我们将测试住院压力(其次是体力活动、睡眠或体重减轻)是否会导致30天的再住院。美国每年有100多万心脏病患者住院，其中20%的患者在30天内再次住院。所有被假设为导致小儿麻痹症的因素都是可以修改的，但需要证据表明它们与再次住院之间的联系才能推动变化。这项研究将是第一个测试是否有必要改变，并提供干预目标的研究。AS 如此一来，本研究的影响是巨大的。

 DESCRIPTION (provided by applicant): The hospital environment was designed for treatment of acute illnesses, and has evolved unsystematically over the past century based on financial, demographic, and political pressures. We have become expert at treating acute cardiac events in particular, but new evidence suggests that hospitalization itself may weaken our patients -- rendering them susceptible to a host of maladies while they recover. A recent study of 500,000 cardiac admissions found that 1 out of every 5 patients was rehospitalized within 30 days of their discharge. Surprisingly, only half of those rehospitalizations were for cardiac reasons. Because of new financial regulations in the Affordable Care Act that tie reimbursement to rehospitalization rates, hospitals are highly motivated to decrease these early rehospitalizations. A new model of "posthospital syndrome" (PHS) suggests that the stress of hospitalization itself confers increased risk of rehospitalization because it places patients in a transient state of generalized risk. Testing this model, and identifying hospital environment and patient factors that place patients at risk, are crucial for directing hospital efforts to reduce 30-day rehospitalizations. The first goal of this proposed research is to test the PHS model to explain the high risk of all-cause rehospitalization experienced by cardiac patients in the 30 days after they are discharged. The second goal is to identify modifiable hospital factors that contribute most to PHS, and by doing so detect targets for reducing early hospital readmissions. The third goal is to identify patient factors, such as personality and social support that may be associated with PHS, so that we can ultimately conduct risk stratification and improve patients' successful transition to independent post-hospital care. We plan to enroll a consecutive cohort of 1,000 cardiac patients who are admitted through the emergency department (ED), follow them throughout their hospitalization, and identify 30-day rehospitalizations. We will assess 4 in-hospital risk factors: stress using ecological momentary assessment (EMA); sleep and physical activity by actigraphy; and weight loss by electronic scale. We will also objectively assess hospital factors that may contribute to stress: stressful environmental factors (degree of ED crowding and length of stay [LOS]; excess noise and lighting throughout hospitalization). Further, we will measure patient factors that may influence the hospital experience, including personality, social support, cardiac severity, and physical and psychiatric comorbidities during and after hospitalization. Finally, we will test whether in-hospital stress (and secondarily, physical activity, sleep, or weight loss) contribute to 30-day rehospitalizations. More than 1 million cardiac patients are hospitalized in the US annually, and 20% are rehospitalized within 30 days. All of the factors that have been hypothesized to contribute to PHS are modifiable, but evidence of their association to rehospitalization is required to motivate change. This study would be the first to test whether change is warranted, and to provide targets for intervention. As such, the impact of this research is substantial.