The Impact of Cardiac Care Regionalization on Access, Treatment, and Outcomes

描述（由申请人提供）：冠心病，包括急性心肌梗死（AMI），是美国的主要死亡原因。ST段抬高型心肌梗死（STEMI）是一种常见且特别严重的急性心肌梗死，及时接受经皮冠状动脉介入治疗（PCI）对良好的患者结局至关重要。为了改善STEMI患者的结局，已经在美国各地的地方和州一级建立了STEMI区域化系统，以快速将STEMI患者路由或转移到一个治疗中心。 有PCI能力的医院。然而，没有研究这个相对较新的医疗保健系统已经能够显示，如果，以及如何，区域化改善了访问和死亡率在社区一级，以前的工作一直受到限制的研究在单一的医院设置，只有某些过程的结果进行评估，并没有纳入一个控制组，以考虑长期的趋势，在改善死亡率。 我们在本提案中的目标有三个方面：（1）确定区域化STEMI系统在多大程度上与接入和结局的改善相关，（2）弱势社区是否在同一系统中平等受益，以及（3）距离和时间如何不同地影响这些结局。为了实现这些目标，我们提出了一个创新的和明确的方法来研究加州，一个国家，提供了一个自然的实验STEMI区域化，其59%的县在不同的时间在研究期间进行区域化。我们将使用差异中的差异方法，并将2006-2011年期间来自加州全州健康规划和发展办公室的非公开患者出院数据（H182，800例STEMI患者）与PI设计的同一时期各县区域化状态数据库相关联。在目标1中，我们将确定区域化社区与非区域化社区中STEMI患者的总体可达性（定义为入住具备PCI能力的医院）、治疗（接受PCI）和健康结局的差异程度。我们假设，在区域化的县中，入住配备PCI的医院和接受PCI的概率变化将明显高于非区域化的县，并且健康结局将得到改善。在目标2中，我们将确定在获得、治疗和 区域化社区与非区域化社区的ST段抬高型心肌梗死患者的结局发生了变化。我们假设，相对于参考人群，属于传统服务不足人群的STEMI患者在区域化后这些指标将有更大的改善。在目标3中，我们将根据区域化后的距离和时间范围，确定STEMI患者的入路、治疗和结局变化的差异程度。我们假设，居住在远离区域PCI中心的STEMI患者将比居住在靠近区域PCI中心的患者受益更多，并且区域化的益处可能要到实施后1-2年才能看到。

DESCRIPTION (provided by applicant): Coronary heart disease, including acute myocardial infarction (AMI), is the leading cause of death in the United States. ST-elevation myocardial infarction (STEMI) is a common and particularly severe form of AMI for which timely access to percutaneous coronary intervention (PCI) is essential to good patient outcomes. In an attempt to improve outcomes for STEMI patients, STEMI regionalization systems have been established at the local and state level across the United States to quickly route or transfer STEMI patients to a hospital with PCI capability. However, no studies of this relatively new healthcare system have been able to show if, and how, regionalization has improved access and mortality at the community level, as prior work has been limited by studies done in single-hospital settings, the evaluation of only certain process outcomes, and the lack of inclusion of a control group to account for secular trends in improved mortality. Our goals in this proposal are 3-fold: (1) to determine to what extent regionalized STEMI systems are associated with improvements in both access and outcomes, (2) whether vulnerable communities benefit equally within the same system, and (3) how distance and time differentially affect these outcomes. To accomplish these goals, we propose an innovative and definitive approach to study California, a state that provides a natural experiment of STEMI regionalization, as 59% of its counties have regionalized at different times over the study period. We will use a difference-in-differences approach and link non-public patient discharge data from the California Office of Statewide Health Planning and Development between 2006-2011 (H182,800 STEMI patients) with a database designed by the PI of the regionalization status of each county over the same period. In Aim 1, we will determine the extent to which overall access (defined by admission to PCI-capable hospital), treatment (receipt of PCI), and health outcomes differ for STEMI patients in regionalized vs. non-regionalized communities. We hypothesize that the change in probability of being admitted to a PCI- equipped hospital and of receiving PCI will be appreciably higher in counties experiencing regionalization than non-regionalized counties and that health outcomes will improve. In Aim 2, we will determine the extent to which disparities in access, treatment, and outcomes have changed for STEMI patients in regionalized vs. non- regionalized communities. We hypothesize that STEMI patients who belong to traditionally underserved populations will have larger improvements in these metrics post-regionalization relative to the reference population. In Aim 3, we will determine the extent to which changes in access, treatment, and outcome differ for STEMI patients according to distance and time horizon following regionalization. We hypothesize that STEMI patients living farther away from regional PCI centers will benefit differentially more than those living closer to regional PCI centers and benefits of regionalization may not be seen until 1-2 years post- implementation.