Kosecoff J, Kahn K L, Rogers W H, Reinisch E J, Sherwood M J, Rubenstein L V, Draper D, Roth C P, Chew C, Brook R H
Value Health Sciences Inc, Santa Monica, Calif. 90404.
JAMA. 1990 Oct 17;264(15):1980-3.
Since the introduction of the prospective payment system (PPS), anecdotal evidence has accumulated that patients are leaving the hospital "quicker and sicker." We developed valid measures of discharge impairment and measured these levels in a nationally representative sample of patients with one of five conditions prior to and following the PPS implementation. Instability at discharge (important clinical problems usually first occurring prior to discharge) predicted the likelihood of postdischarge deaths. At 90 days postdischarge, 16% of patients discharged unstable were dead vs 10% of patients discharged stable. After the PPS introduction, instability increased primarily among patients discharged home. Prior to the PPS, 10% of patients discharged home were unstable; after the PPS was implemented, 15% were discharged unstable, a 43% relative change. Efforts to monitor the effect of this increase in discharge instability on health should be implemented.
自从实行前瞻性支付系统（PPS）以来，已有传闻证据表明患者出院时“更快但病情更重”。我们制定了有效的出院损伤衡量标准，并在PPS实施前后，对患有五种疾病之一的具有全国代表性的患者样本进行了这些水平的测量。出院时的不稳定情况（重要临床问题通常在出院前首次出现）预示着出院后死亡的可能性。出院90天后，不稳定出院患者的死亡率为16%，而稳定出院患者的死亡率为10%。引入PPS后，不稳定情况主要在居家出院的患者中增加。在PPS实施之前，10%的居家出院患者不稳定；PPS实施后，15%的患者出院时不稳定，相对变化为43%。应努力监测出院不稳定情况增加对健康的影响。
