Instability on Hospital Discharge and the Risk of Adverse
Outcomes in Patients With Pneumonia
Ethan A. Halm, MD, MPH; Michael J. Fine, MD, MSc; Wishwa N. Kapoor, MD,
MPH; Daniel E. Singer, MD; Thomas J. Marrie, MD; Albert L. Siu, MD, MSPH
Background Investigating claims that patients are being sent home from the
hospital "quicker and sicker" requires a way of objectively measuring
appropriateness of hospital discharge.
Objective To define and validate a simple, usable measure of clinical
stability on discharge for patients with community-acquired pneumonia.
Methods Information on daily vital signs and clinical status was collected
in a prospective, multicenter, observational cohort study. Unstable factors in
the 24 hours prior to discharge were temperature greater than 37.8°C, heart
rate greater than 100/min, respiratory rate greater than 24/min, systolic blood
pressure lower than 90 mm Hg, oxygen saturation lower than 90%, inability to
maintain oral intake, and abnormal mental status. Outcomes were deaths,
readmissions, and failure to return to usual activities within 30 days of
discharge.
Results Of the 680 patients, 19.1% left the hospital with 1 or more
instabilities. Overall, 10.5% of patients with no instabilities on discharge
died or were readmitted compared with 13.7% of those with 1 instability and
46.2% of those with 2 or more instabilities (P<.003).
Instability on discharge (1 unstable factor) was
associated with higher risk-adjusted rates of death or readmission (odds ratio
[OR], 1.6; 95% confidence interval [CI], 1.0-2.8) and failure to return to
usual activities (OR, 1.5; 95% CI, 1.0-2.4). Patients with 2 or more
instabilities had a 5-fold greater risk-adjusted odds of death or readmission
(OR, 5.4; 95% CI, 1.6-18.4).
Conclusions Instability on discharge is associated with adverse clinical
outcomes. Pneumonia guidelines and pathways should include objective criteria
for judging stability on discharge to ensure that efforts to shorten length of
stay do not jeopardize patient safety.
Arch Intern Med.
2002;162:1278-1284
OVER THE past 15 years, hospital length of stay
has fallen dramatically. Studies assessing the impact of the prospective
payment system on hospital care of Medicare beneficiaries in the 1980s
indicated that this shortening length of stay was accompanied by a 43% relative
increase in patients being sent home clinically unstable with unresolved
medical issues.1, 2 This was worrisome
because Medicare beneficiaries who were discharged unstable had a 60% greater
odds of death.2 This has been called
the "quicker and sicker" phenomenon. The widespread diffusion of
managed care throughout the 1990s has resulted in even more dramatic declines
in the length of stay for many common conditions, including pneumonia.3 With patients needing
to be sicker than ever to justify admission and the duration of hospital stays
becoming even shorter, many providers, patients, and policy makers have
expressed concern that patients are being sent home quicker and sicker than
ever.4-8
Investigating these claims in an unbiased
fashion requires a way of objectively measuring appropriateness of hospital
discharge. In general, federal and state legislative and regulatory approaches
have focused on the duration of hospital stay.6 Unfortunately, since
the landmark RAND study in the early 1990s,2 there have been few,
if any, clinical indicators proposed that empirically assess readiness for
hospital discharge. The RAND measure of instability on discharge, which was
developed in the 1980s, has the limitations of not including some factors that
are now considered core vital signs (such as oxygen saturation), while
including others that are no longer thought to have major clinical significance
(eg, premature ventricular contractions).
In a previous study, we developed a
pneumonia-specific measure of clinical stability that was based on a smaller
number of key clinical variables, included key variables such as oxygenation,
and used vital sign cut points that more closely corresponded to traditional
thresholds than the original RAND criteria (eg, heart rate is stable if 100/min vs RAND cut point of
<130/min).2, 9, 10 Our definition of
clinical stability was based on temperature, heart rate, blood pressure,
respiratory rate, oxygenation, mental status, and ability to maintain oral
intake. These factors have been identified by physicians as important for
deciding when to switch from intravenous to oral antibiotics10 and how to judge
appropriateness for hospital discharge.11 Once someone with
pneumonia was stable according to this disease-specific definition of
stability, the risk of serious clinical deterioration during the rest of their
hospital stay was 1% or less, even in the sickest subgroup of patients.9
From a patient safety perspective, it is equally
important to assess the relationship between stability on discharge and
posthospital outcomes. Among patients with pneumonia, the rates of death,
readmission, and delayed return to usual activities in the 30 days after
leaving the hospital are substantial.12-14 The specific aims
of the present study were to (1) describe rates and types of instability on
discharge, (2) examine associations between instability on discharge and a
range of posthospital outcomes, and (3) determine if instability on discharge
influences the risk of adverse events even after adjusting for other important
prognostic factors and potential confounders. Our hypothesis was that the
greater the number of instabilities on discharge, the greater the risk of
adverse outcomes following discharge.
STUDY POPULATION AND SITES
The present study was part of the Pneumonia Patient Outcomes Research Team
(PORT) cohort study (a prospective, multicenter, observational study of
outcomes in hospitalized and ambulatory patients with community-acquired
pneumonia). Complete details about the Pneumonia PORT cohort study have been
described previously.12, 15 Study inclusion
criteria were (1) age 18 years or older, (2) symptoms of acute pneumonia, and
(3) radiographic evidence of pneumonia. Patients were excluded if they were
human immunodeficiency virus positive or had been hospitalized within 10 days.
As part of a substudy on all hospitalized
patients enrolled in the Pneumonia PORT cohort study, detailed daily inpatient
data were collected during 2 consecutive sampling periods. During period 1
(October 15, 1991, through May 14, 1993), medical record review was done on
consecutive low-risk patients (<4% predicted risk of death). During period 2
(May 15, 1993, through March 31, 1994), medical record review was done on all
consecutive hospitalized patients regardless of mortality risk. This strategy
captured 680 patients who were discharged alive from the overall Pneumonia PORT
cohort study of 1343 inpatients. Because we oversampled low-risk patients during
period 1, the 680 patients in the detailed daily assessment cohort we report on
in the present study were younger (mean age, 61 vs 74 years) and had lower
predicted 30-day mortality (2% vs 6%) than patients in the overall Pneumonia
PORT study who did not have daily medical record review. The mortality rates
for all inpatients enrolled during study periods 1 and 2 (prior to exclusion of
high risk cases in period 1) were the same (7% vs 6%). There were no
differences in the mortality rates for patients entered in the 2 sampling
periods when we stratified by admission mortality risk class as defined by the
Pneumonia Severity Index (PSI), a multivariable logistic model of short-term
mortality described below.15
The participating inpatient sites (and number of
patients enrolled) were the University of Pittsburgh Medical Center and St
Francis Medical Center, Pittsburgh, Pa (214 and 59, respectively); the
Massachusetts General Hospital, Boston (243); and the Victoria General
Hospital, Halifax, Nova Scotia (164). The study was conducted from October 15,
1991, through March 31, 1994, and was approved by the institutional review
board of all participating institutions.
BASELINE DATA, DAILY MEASUREMENTS,
AND DEFINITIONS OF STABILITY
Information on sociodemographic characteristics, initial pneumonia severity,
comorbid conditions, vital signs, mental status, ability to eat, physical
examination findings, laboratory results, and chest radiography findings was
collected on admission. Pneumonia severity was assessed usingthe PSI, which is
a well-validated, disease severity classification using a 20-variable composite
score based on age, sex, nursing home residence, 5 comorbid illnesses, vital signs
on admission, mental status, and 7 laboratory and chest radiography findings
from presentation.15 Class I patients have
the least severe disease, and class V patients, the most severe disease. The
PSI has been shown to be a robust predictor of a full range of 30-day outcomes
including mortality, readmissions, and return to usual activities.12, 15-18
The highest temperature, heart rate, and
respiratory rate and the lowest systolic blood pressure, oxygen saturation, and
PaO2 of each hospital day was abstracted from the medical record.
Nearly all temperatures on the hospital ward were measured orally. The
patient's mental status and ability to eat each day were also recorded. A
patient was considered to be stable on discharge if their temperature, heart
rate, respiratory rate, systolic blood pressure, oxygenation, ability to eat,
and mental status were all stable in the 24-hour period prior to discharge.9 Stable values for
vital signs were selected prior to analysis based on the clinical literature
and common clinical practice.2, 10 The stability cut
point for temperature was 37.8°C or lower; heart rate, 100/min or lower;
systolic blood pressure, 90 mm Hg or higher; and respiratory rate, 24/min or
lower.
Oxygenation was considered stable if the oxygen
saturation rate was 90% or higher or the PaO2 was 60 mm Hg or higher
and a patient was not receiving mechanical ventilation or supplemental oxygen
by face mask. We did not know the oxygen flow rate for patients who received
supplemental oxygen by nasal prongs. Therefore, we regarded these patients to have
stable oxygenation if they had an oxygen saturation rate of 95% or higher. If
oxygenation was not measured on a given day, the value of the most recent
assessment was used. The mean last day that oxygen saturation was measured was
6.4 days. Patients who used home oxygen prior to admission were not considered
to have unstable oxygenation on discharge.
Mental status was considered stable if the
patient was either normal or, for those with chronic dementia, back to
baseline. Patients who were able to eat (or resumed long-term tube feeding)
were counted as having stable eating status. The number of instabilities on
discharge was defined as the number of vital sign and clinical status factors
that did not meet the above criteria in the 24 hours prior to leaving the
hospital.
CLINICAL OUTCOMES
All patients received a standard telephone follow-up call 30 days after
discharge to ascertain survival, readmissions, and return to their usual
activities. Any death or readmission within 30 days of discharge was considered
a major event. Patients who died after being readmitted were only counted as
having 1 major event. We constructed this composite outcome because we believed
that either adverse outcome could be a marker of a patient being sent home
prior to being clinically ready.
STATISTICAL ANALYSES
Means SDs are
presented for normal data and medians with interquartile ranges (IQRs) for
nonnormal data. We used logistic regression to examine the association between
the number of instabilities on discharge and the risk of death, readmission,
major events, and failure to return to usual activities within 30 days of
hospital discharge. Candidate variables entered into the multivariable models
were PSI score, do not resuscitate (DNR) status, number of comorbid conditions,
presence of chronic obstructive pulmonary disease, use of home oxygen,
discharge to a skilled nursing home facility, discharge against medical advice,
and receipt of posthospital home health services. Covariates that were
significant at the 2-tailed level of P<.05
were retained in the final multivariable models. All other analyses also used
2-tailed significance levels of P<.05
and were conducted with SAS statistical software (version 6.12; SAS Institute,
Cary, NC). Using the Kaplan-Meier and Cox proportional hazards methods, we
found similar associations between instabilities on discharge and the time to
death, readmission, or failure to return to usual activities within 30 days as
those produced by the primary logistic regression models we report herein. The
sensitivity, specificity, positive predictive value, and negative predictive
value of 2 definitions of instability on discharge to identify death or
readmission within 30 days were calculated in the standard fashion.19
PATIENT CHARACTERISTICS
Characteristics of the study subjects are summarized in Table 1.
The patients' mean age was 57.9 19.3 years
(range, 18-101 years). Half (352) of the sample were women. According to the
PSI score on admission, 70% of patients were low-risk cases (class I-III), 20%
were moderate risk (class IV), and 8%, high risk (class V). One quarter (165)
of patients had 1 major comorbid illness, and half (345) had 2 or more.
VITAL SIGNS ON DISCHARGE AND
RATES OF INSTABILITY
The mean length of hospital stay was 9.2 8.9 days (median, 7 days; IQR, 5-10 days). The mean length of stay
ranged from 7.7 to 11.3 days among the 4 sites. The mean vital sign measures on
discharge were a temperature of 36.7°C 0.60°C, a heart rate of 82.4/min 12.39/min, a respiratory rate of 20.8/min 3.3/min, a systolic blood pressure of 121.6 mm Hg 19.0 mm Hg, and an oxygen saturation rate of 93.6% 4.7%. The
incidence of unstable vital signs on discharge ranged from 1% for a systolic
blood pressure of 90 mm Hg or lower to 5.9% for an oxygen saturation rate of
90% or lower (Table 2).
Mental status and ability to maintain oral intake were both abnormal in fewer
than 2% of patients.
Overall, 130 patients (19%) had 1 or more
instabilities on discharge. Among the 117 patients with 1 instability on
discharge, the most common abnormalities were oxygenation (32%), respiratory
rate (16%), heart rate (16%), temperature (15%), mental status (8%), eating
status (7%), and systolic blood pressure (4%). Twelve patients had 2
instabilities on discharge, and 1 patient had 3 abnormalities. Among patients
with more than 1 instability on discharge, no specific combination of
abnormalities dominated. There were no differences in rates of instability on
discharge among the 4 study sites (range, 18.9%-20.6%).
OUTCOMES
In the 30 days after discharge, 23 patients (3.4%) died; the median time to
death was 18 days (IQR, 8-24 days). Sixty-seven patients were readmitted within
30 days (9.9% readmission rate); the median time of readmission was 10 days
(IQR, 4-16 days). Overall, 80 patients died or were readmitted within 30 days
of discharge (major adverse events rate, 11.8%). Ten patients died after
readmission to the hospital. Patients admitted from a nursing home accounted
for 15.0% of major events. We had data on return to usual activities for 641
patients. Overall, 223 patients (32.8%) did not return to their usual
activities within 30 days of discharge.
UNIVARIABLE ASSOCIATIONS
BETWEEN INSTABILITY ON DISCHARGE AND OUTCOMES
The greater the number of instabilities on discharge, the greater the risk of
death, readmissions, major events, and failure to return to usual activities (P<.05 for all) (Figure 1).
For example, 10.5% of patients with no instabilities on discharge died or were
readmitted within 30 days compared with 13.7% of those with 1 instability and
46.2% of those with 2 or more instabilities (P
= .003). When we considered patients with any instabilities on discharge as
unstable, we found that those who left the hospital prior to reaching stability
had higher rates of death (odds ratio [OR], 2.8; 95% confidence interval [CI],
1.2-6.7; P = .02), readmission
(OR, 1.6; 95% CI, 0.9-2.9; P =
.09), major events (OR, 1.8; 95% CI, 1.0-3.0; P
= .04), and failure to return to usual activities (OR, 1.7; 95% CI, 1.1-2.6; P = .009) within 30 days (Table 3).
Compared with patients with no instabilities on
discharge, those with 1 unstable factor had modestly increased odds of death or
readmission (OR, 1.4; 95% CI, 0.8-2.5) and not returning to usual activities
(OR, 1.6; 95% CI, 1.1-2.5) (Table 3).
In contrast, having 2 or more instabilities on discharge increased the risk of
major events (death or readmission) 7-fold (OR, 7.4; 95% CI, 2.4-22.8), with a
trend toward doubling the chance of not returning to usual activities (OR, 2.5;
95% CI, 0.8-8.3). We also found a similar relationship between instabilities on
discharge and risk of adverse outcomes at 7 and 14 days when complications are
most likely to be purely pneumonia related (data not shown).
MULTIVARIABLE ASSOCIATIONS
BETWEEN INSTABILITY ON DISCHARGE AND OUTCOMES
The number of instabilities on discharge remained significantly associated with
posthospital outcomes even after controlling for other important prognostic
factors and potential confounders including: the admission PSI score and DNR
status. Patients with any instabilities on discharge had higher risk-adjusted
rates of major events (OR, 1.6; 95% CI, 1.0-2.8; P<.05) and failure to return to usual activities (OR,
1.5; 95% CI, 1.0-2.4; P = .04)
within 30 days (Table 3).
Those persons with 2 or more instabilities on discharge experienced
dramatically higher risk-adjusted rates of death (OR, 14.1; 95% CI, 3.1-69.0),
readmission (OR, 3.5; 95% CI, 1.0-12.4), and total major events (OR, 5.4; 95%
CI, 1.6-18.4). Forcing other potentially important clinical variables such as
the presence of chronic obstructive pulmonary disease or use of home oxygen
therapy into the multivariable model did not alter our findings.
We also performed a series of stratified
analyses to assess whether certain subgroups might be more sensitive to the
hazards related to clinical instability. Among the 54 patients (7.9%) who were
DNR, 24.1% were discharged prior to reaching stability compared with 18.7% who
were not DNR (P = .33). Analyses
that stratified by DNR status revealed that instability on discharge was
associated with higher risk of poor outcomes in all subgroups. Similarly,
instability on discharge increased the risk of major events across the PSI risk
strata.
One of our secondary hypotheses was that patients
who were unstable on discharge would be more likely to be sent to a monitored
setting such as a skilled nursing facility and be spared adverse consequences
compared with patients returning home. The greater the number of instabilities
a patient had on discharge, the more likely they were to be discharged to a
skilled nursing facility (10.5% of patients with no instabilities on discharge,
14.9% of those with 1 instability on discharge, and 41.7% of those with 2 or
more instabilities on discharge were institutionalized; P = .007). However, instability on
discharge remained a significant predictor of risk-adjusted rates of death,
readmissions, major events, and failure to return to usual activities even
after stratifying by discharge to a skilled nursing facility (P<.05 for all). Nor were the adverse
outcomes of instability on discharge mitigated among patients sent home with
visiting nurse services compared with those who went home alone.
We found no significant relationship between
hospital length of stay and instability on discharge. For example, the median
length of stay was 7 days (IQR, 5-10 days) in those with no instabilities, 8
days (IQR, 6-11 days) for those with 1 instability, and 6 days (IQR, 5-9 days)
for patients with 2 or more instabilities (P
= .19); the median length of stay was 8 days (IQR, 6-11 days) among patients
with 1 or more instabilities (P =
.28). Nor were there any associations between the natural logarithm of length
of stay (or stays shorter than 4 days) and instability on discharge.
TEST OPERATING CHARACTERISTICS
OF INSTABILITY ON DISCHARGE
From a clinical perspective, individual physicians or medical groups may want
to use a specific definition of instability to help gauge appropriateness for
hospital discharge. In this respect, the instability criteria may be considered
a type of diagnostic test for future adverse events. The sensitivity,
specificity, and predictive values of the 2 definitions of instability are displayed
in Table 4.
Instability defined as any abnormalities (1) was
more sensitive than the more extreme definition of 2 or more abnormalities
(27.5% vs 7.5%), but less specific (83.1% vs 98.8%). To put the prognostic
value of the instability information in context, knowing that a patient had 2
or more instabilities on discharge was a better predictor of the risk of death
or readmission (positive predictive value, 46.1%) than knowing that they were
DNR (positive predictive value, 35.1%) or in the highest pneumonia risk group
(PSI class V) on admission (positive predictive value, 28.6%).
The negative predictive value of the instability
information was 89% for both definitions. There were 58 patients who were
discharged with no instabilities but who went on to die or be readmitted within
30 days. These patients had a worse initial prognosis than the overall cohort.
Half of these patients had moderate- or high-risk pneumonia on admission
(50.0%), 24.1% were DNR, and 19.3% were discharged to a nursing home. They had
similar socioeconomic status as the overall group.
In this multicenter, prospective cohort study,
nearly 1 in 5 patients with pneumonia left the hospital with 1 or more unstable
vital sign or clinical status factor. Leaving the hospital prior to becoming
stable had important clinical consequences because the greater the number of
instabilities, the greater the risk of death or readmission and failure to
return to usual activities. Patients with any one of 7 unstable factors on
discharge had a 60% increased odds of death or readmission and a 50% increased
odds of not returning to their usual activities in the 30 days after discharge,
even after adjusting for other important prognostic factors and potential
confounders. Among the small group of patients with 2 or more unstable factors
on discharge, the risk of major adverse events increased 5-fold.
We deliberately defined stability in a
clinically simple manner based on vital signs, oxygenation, ability to eat, and
mental status. All of these factors are measured in everyday practice and have
been identified by physicians as very important in deciding the readiness to
switch to oral antibiotics and appropriateness for hospital discharge.11 We have previously
shown that once a patient is stable by these criteria, the risk of serious
clinical deterioration during the index hospitalization was 1% or less, even in
the sickest subgroup of patients.9 It is now clear that
the same criteria are strongly associated with a range of important medical
outcomes following discharge. Instability on discharge remained an important
marker of posthospital adverse outcomes even after adjusting for pneumonia
severity, comorbid illness burden, DNR status, and discharge location. The
instability criteria outlined herein can help a clinician or case manager to quickly
ascertain if a given patient is safe for discharge (in the absence of
extenuating medical or social circumstances).
Which of the 2 instability criteria modeled in
our study is to be recommended? Unfortunately, we have no easy answer to this
question. The more conservative definition (1
instability) identified more patients at risk for doing poorly (but at a higher
false-positive rate) compared with the less conservative definition (2 instabilities) in which
the opposite was true. There was no doubt that patients with 2 or more
instabilities had extremely high rates of poor outcomes and should not be
discharged in the absence of extenuating circumstances. Individual clinicians
will need to decide for themselves if just 1 instability on discharge is an
absolute reason for continued hospitalization, since the associated increased
risk of adverse events was more modest. Though we weighed all instabilities
equally to facilitate feasibility and use in real world practice, findings from
additional analyses suggest that inability to eat and hypotension, though
uncommon, were more serious single indicators of the risk of adverse events.
All of the other factors had relatively similar prognostic weights.
Our definition of stability differed from the
one used in the original RAND study of instability on discharge in several
ways.2 The criteria we
used were disease specific (eg, oxygenation), had fewer elements, and were
based on vital sign cut points closer to traditional values for stability (eg,
heart rate 100/min vs 130/min).10 However, despite the
differences in methodology, time, and patient population studied, Kosecoff and
colleagues2 also reported
an association of similar magnitude between instability on discharge and
short-term mortality. As expected, the more extreme cut points (eg, temperature
>38.4°C or heart rate >130/min), which were used in the original RAND
study, have greater specificity for predicting adverse events, though with the
trade-off of lower sensitivity.
Our study had several strengths such as its
multicenter, prospective nature; clinically simple definition of stability;
focus on both fatal and nonfatal outcomes; and use of well-validated,
disease-specific risk adjustment tools. Some limitations are worth noting.
Because this was an observational study, we cannot unambiguously infer
causality. We do not know what would have happened if patients we identified as
unstable on discharge had stayed in the hospital longer instead of being sent
home. However, we do know from previous work that most patients will stabilize
over time.9 There may have
been some patients who were sent home prior to attaining stability because the
physician and patient desired intentionally less aggressive care. This was one
of the reasons why we controlled for DNR status. While we observed a trend
toward patients who were DNR being more likely to be discharged unstable,
instability on discharge exposed all patients to increased risk of poor
outcomes regardless of advanced directive status.
Because we did not have data on all vital signs
in the 24 hours prior to discharge, it is possible that some of the patients we
identified as unstable may have had 1 set of stable vital signs on discharge.
However, we knew the most abnormal value of the day, such as the highest
temperature, which usually factors heavily into medical decision making. In any
event, any abnormalities in the 24 hours prior to discharge increased the risk
of adverse outcomes. Finally, our data reflect the medical practice from 1991
to 1994, when there was considerably less pressure to shorten length of stay.
We expect that rates of instability on discharge are likely to be higher today,
which would only strengthen the importance of our findings.
Physicians should be aware that instability in
the 24 hours prior to discharge increases the risk of poor posthospital
outcomes. At a minimum, patients with 1 instability on discharge should have
close outpatient follow-up and appropriate patient education about warning
signs and symptoms that merit urgent medical attention. Persons with 2 or more
instabilities should almost certainly remain in the hospital for continued
treatment and observation in the absence of extenuating circumstances. From a
policy standpoint, pneumonia practice guidelines and critical pathways should
include objective criteria for judging stability on discharge to ensure that
efforts to reduce length of stay do not jeopardize patient safety. Our findings
may also have implications for quality measurement and improvement efforts. The
2 main national quality indicators for pneumonia care focus primarily on
initial management (antibiotic selection and time to first dose of
antibiotics).20-22 Our data would
support including the proportion of patients discharged prior to attaining
clinical stability as a complementary patient safety indicator with which to
compare provider or health plan performance and stimulate quality improvement
initiatives.
Author/Article Information
From the Department of Health Policy and Division of General Internal Medicine,
Mount Sinai School of Medicine, New York, NY (Drs Halm and Siu); the Division
of General Internal Medicine and Center for Research on Health Care, University
of Pittsburgh, Pittsburgh, Pa (Drs Fine and Kapoor); VA Pittsburgh Center for
Health Services Research, VA Pittsburgh Healthcare System, Pittsburgh (Dr
Fine); the General Medicine Division, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School, Boston (Dr Singer); and the
Department of Medicine, University of Alberta, Edmonton (Dr Marrie).
Corresponding author: Ethan A. Halm, MD, MPH, Department of Health Policy, Box
1077, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY
10029 (e-mail: [log in to unmask]).
Accepted for publication October 2, 2001.
This study was supported by grant HS09973 from
the Agency for Healthcare Research and Quality, Rockville, Md, and grant
HS06468 from Pneumonia PORT. Dr Halm is also currently supported as a
Generalist Physician Faculty Scholar by the Robert Wood Johnson Foundation,
Princeton, NJ.
This study was originally presented in part at
the 23rd Annual Meeting of the Society of General Internal Medicine, Boston,
Mass, May 4, 2000.
1.
Kahn KL, Keeler EB, Sherwood MJ, et al.
Comparing outcomes of care before and after implementation of the DRG-based
prospective payment system.
JAMA.
1990;264:1984-1988.
MEDLINE
2.
Kosecoff J, Kahn KL, Rogers WH, et al.
Prospective payment system and impairment at discharge: the
"quicker-and-sicker" story revisited.
JAMA.
1990;264:1980-1983.
MEDLINE
3.
Metersky ML, Tate JP, Fine MJ, Petrillo MK, Meehan TP.
Temporal trends in outcomes of older patients with pneumonia.
Arch Intern Med.
2000;160:3385-3391.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
4.
Brook RH, Kahn KL, Kosecoff J.
Assessing clinical instability at discharge: the clinician's responsibility.
JAMA.
1992;268:1321-1322.
MEDLINE
5.
Prager LO.
Pediatric hospital stay goals questioned.
American Medical News.
October 16, 2000:39.
6.
Newborns' and Mothers' Health Protection Act of 1996.
Pub L No. 104-204, 110 Stat 2935.
7.
Gordon S, McCall TB.
As hospital stay gets shorter, we pay a price.
Boston Globe.
May 4, 1998:A19.
8.
Steinhauer J.
Length of stay is target for HMOs.
New York Times.
October 19, 1999:B1.
9.
Halm EA, Fine MJ, Marrie TJ, et al.
Time to clinical stability in patients hospitalized with community acquired
pneumonia: implications for practice guidelines.
JAMA.
1998;279:1452-1457.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
10.
Halm EA, Mittman BS, Walsh MB, Switzer GE, Chang CH, Fine MJ.
What factors influence physicians' decisions to switch from intravenous to oral
antibiotics for community-acquired pneumonia?
J Gen Intern Med.
2001;16:599-605.
MEDLINE
11.
Fine MJ, Medsger AR, Stone RA, et al.
The hospital discharge decision for patients with community-acquired pneumonia:
results from the Pneumonia Patient Outcomes Research Team cohort study.
Arch Intern Med.
1997;157:47-56.
MEDLINE
12.
Fine MJ, Stone RA, Singer DE, et al.
Processes and outcomes of care for patients with community-acquired pneumonia:
results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study.
Arch Intern Med.
1999;159:970-80.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
13.
Minogue MF, Coley CM, Fine MJ, Marrie TJ, Kapoor WN, Singer DE.
Patients hospitalized after initial outpatient treatment for community-acquired
pneumonia.
Ann Emerg Med.
1998;31:376-380.
MEDLINE
14.
Metlay JP, Fine MJ, Schulz R, et al.
Measuring symptomatic and functional recovery in patients with
community-acquired pneumonia.
J Gen Intern Med.
1997;12:423-430.
MEDLINE
15.
Fine MJ, Auble TE, Yealy DM, et al.
A prediction rule to identify low-risk patients with community-acquired
pneumonia.
N Engl J Med.
1997;336:243-250.
MEDLINE
16.
Fine MJ, Singer DE, Hanusa BH, Lave JR, Kapoor WN.
Validation of a pneumonia prognostic index using the MedisGroups Comparative Hospital
Database.
Am J Med.
1993;94:153-159.
MEDLINE
17.
Fine MJ, Hanusa BH, Lave JR, et al.
Comparison of a disease-specific and a generic severity of illness measure for
patients with community-acquired pneumonia.
J Gen Intern Med.
1995;10:359-368.
MEDLINE
18.
McCormick D, Fine MJ, Coley CM, et al.
Variation in length of hospital stay in patients with community-acquired pneumonia:
are shorter stays associated with worse medical outcomes?
Am J Med.
1999;107:5-12.
MEDLINE
19.
Sackett DL, Haynes RB, Guyatt GH, Tugwell P.
Clinical Epidemiology: A Basic Science for
Clinical Medicine.
2nd ed. Boston, Mass: Little Brown & Co Inc; 1991.
20.
Meehan TP, Fine MJ, Krumholz HM, et al.
Quality of care, process, and outcomes in elderly patients with pneumonia.
JAMA.
1997;278:2080-2084.
MEDLINE
21.
Gleason PP, Meehan TP, Fine JM, Galusha DH, Fine MJ.
Associations between initial antimicrobial therapy and medical outcomes for
hospitalized elderly patients with pneumonia.
Arch Intern Med.
1999;159:2562-2572.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
22.
Jencks SF, Cuerdon T, Burwen DR, et al.
Quality of medical care delivered to Medicare beneficiaries: a profile at state
and national levels.
JAMA.
2000;284:1670-1676.
ABSTRACT
| FULL TEXT
| PDF
| MEDLINE
Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.