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

救护车改道的预测因素：医院是否有策略地改道以避免医疗补助和未参保的患者

• 批准号: 9002879
• 负责人: CHARLEEN HSUAN
• 金额: $ 3.38万
• 依托单位: UNIVERSITY OF CALIFORNIA LOS ANGELES
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-09-30 至 2016-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9002879
• 关键词: Predictors; Ambulance; Diversions; Do; Hospitals

 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.

 描述（由申请人提供）：《紧急医疗和劳工法案》(EMTALA) 是参加 Medicare 的一项条件，要求医院为所有患者提供紧急护理，无论其保险状况如何。当医院怀疑救护车载有贫困患者时（例如附近的安全网医院正在改道时），医院可能会策略性地暂时关闭急诊科 (ED)，从而规避 EMTALA。本论文探讨了医院是否宣布这些“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，战略转移加剧了不平等。此外，由于不必要地限制了急诊室的容量，战略转移会威胁到所有患者的护理，因为急诊室护理的延误会增加死亡率。 AHRQ 对这篇论文特别感兴趣，该机构旨在使医疗保健更安全、更容易获得和更公平。该项目将实现三个目标。目标 1 是构建一个数据集，描述宣布分流的医院之间的时间关系。该数据集结合了来自加利福尼亚州急诊室的救护车分流日志的数据以及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。目标 2 是检查医院是否进行战略转移。为了区分这些转移和必要的“容量驱动的转移”，该研究根据规模和距离匹配医院，并使用具有医院随机效应的多元概率和泊松来检查附近安全网和匹配的非安全网医院转移后的转移概率和特征。转院特征包括转院时长以及两家医院结束转院之间的时间间隔。主要预测变量是附近医院的安全网状态，与急诊室拥挤和人员配置的变量（包括每日急诊室占用率）相互作用，并使用工具变量来解决对反向因果关系的担忧。目标 3 是探讨影响医院是否宣布战略转移的因素，例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，但添加了有关利润状况、医院提供的服务的盈利能力以及医院的医疗补助/无保险就诊的预测因素。