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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
Arch Intern Med. 2002;162:1278-1284.
ABSTRACT
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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.
INTRODUCTION
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.
SUBJECTS AND METHODS
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
RESULTS
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.
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Table 1. Characteristics of 680 Patients Hospitalized With Community-Acquired
Pneumonia*
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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.
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Table 2. Frequency of Unstable Vital Sign and Clinical Status Factors
on Discharge*
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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).
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Number of instabilities on discharge and rates of 30-day adverse
outcomes. Major events were defined as death or readmission within 30 days
of discharge. Not RTUA indicates not returned to usual activities within 30
days of discharge.
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Table 3. Effects of Instability on Discharge on Unadjusted and Risk-Adjusted
30-Day Outcomes*
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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%).
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Table 4. Sensitivity, Specificity, and Predictive Values of 2 Different
Definitions of Instability on Discharge to Detect Major Adverse Events Within
30 Days of Discharge*
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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.
COMMENT
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.
CONCLUSIONS
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 INFORMATION
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.
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: ethan.halm{at}mountsinai.org).
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).
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