Predictors of Ambulance Diversions: Do Hospitals Strategically Divert to Avoid Medicaid and Uninsured Patients

 描述（由申请人提供）：紧急医疗和劳动法（EMTALA）是参加医疗保险的条件，要求医院为所有患者提供紧急护理，无论其保险状况如何。当医院怀疑救护车上有贫困患者时，例如附近的安全网医院正在分流时，医院可以通过战略性地暂时关闭急诊科来规避EMTALA。本论文探讨医院是否宣布这些“战略转移”，以及驱动它们的因素。由于医院试图选择经济上有利的患者组合，战略转移增加了不公平。此外，由于他们不必要地限制了艾德的能力，战略转移威胁到所有患者的护理，因为艾德护理的延迟增加了死亡率。这篇论文是特别感兴趣的AHRQ，其目的是使医疗保健更安全，更方便，更公平。该项目将实现三个目标。目的1是构建一个数据集，描述了宣布转移的医院之间的时间关系。该数据集结合了来自加州救护车分流日志、艾德和来自全州卫生规划和发展办公室以及美国医院协会年度调查的住院患者出院数据。目的2是检查医院是否参与战略转移。为了区分这些转移和必要的，“能力驱动的转移，”该研究匹配医院的规模和距离，并使用多变量概率和泊松与医院随机效应，检查转移概率和特点后，附近的安全网和匹配的非安全网医院转移。分流的特点包括分流的长度和两所医院结束各自分流之间的时间。主要的预测变量是附近医院的安全网状态与操作艾德拥挤和人员配置的变量相互作用，包括每日艾德占用，并使用工具变量来解决反向因果关系的问题。目的3是探讨影响医院是否宣布战略转移的因素，如组织文化和目标或转移的预期经济效益。它使用与上述相同的分析，但增加了有关利润状况，医院提供的服务的盈利能力以及医院的医疗补助/无保险访问的预测因素。

 DESCRIPTION (provided by applicant): The Emergency Medical Treatment and Labor Act (EMTALA), a condition of participation for Medicare, requires hospitals provide emergency care to all patients, regardless of insurance status. Hospitals may circumvent EMTALA by strategically temporarily closing their emergency departments (EDs) when they suspect ambulances contain indigent patients, such as when a nearby safety net hospital is on diversion. This dissertation explores whether hospitals declare these "strategic diversions," and the factors driving them. Strategic diversions increase inequities due to hospitals' attempts to select an economically favorable patient mix. Additionally, because they unnecessarily restrict ED capacity, strategic diversions threaten all patients' care since delays in ED care increase mortality. This dissertation is of particular interest to AHRQ, which aims to make health care safer, more accessible, and equitable. The project will address three aims. Aim 1 is to construct a dataset that describes the temporal relationship between hospitals declaring diversions. This dataset combines data from ambulance diversion logs in California, ED and inpatient discharge data from the Office of Statewide Health Planning and Development, and from the American Hospital Association Annual Survey. Aim 2 is to examine whether hospitals engage in strategic diversions. To distinguish between these diversions and necessary, "capacity-driven diversions," the study matches hospitals by size and distance, and uses multivariate probit and poisson with hospital random effects to examine diversion probability and characteristics after nearby safety net and matched non-safety net hospitals divert. Diversion characteristics include length of diversion and time elapsing between when the two hospitals end their respective diversions. The main predictor variables are the safety net status of the nearby hospital interacted with variables operationalizing ED crowding and staffing, including daily ED occupancy, and uses instrumental variables to address concerns about reverse causality. Aim 3 is to explore factors that influence whether hospitals declare strategic diversions, such as organizational culture and goals or the anticipated economic benefit of diverting. It uses the same analyses above but adds predictors about profit status, the profitability of services offered by the hospital, and the Medicaid/uninsured visits at the hospital.