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

项目总结 冠心病，包括急性心肌梗死(AMI)，是导致人类死亡的主要原因 美国。因为ST段抬高心肌梗死(STEMI)需要及时进行经皮冠状动脉介入治疗 冠状动脉介入治疗(PCI)，许多社区已经创建了区域化STEMI护理系统，在其中 指定医院随时提供急诊介入治疗能力。区域化很可能会有意想不到的 对非STEMI(NSTEMI)护理的影响，因为患者和紧急医疗服务提供者可能 越来越多的人到冠状动脉介入治疗中心寻求治疗，而冠状动脉介入治疗中心和非冠状动脉介入治疗中心可能会改变他们对NSTEMI的护理 病人。由于NSTEMI的数量与STEMI的数量之比高达三比一，并且其一年死亡率高于 STEMI，了解区域化对NSTEMI护理和结果的影响对于 政策制定者和卫生系统，如果他们选择实施心脏护理区域化。 我们在这项建议中的目标有三个：(1)确定STEMI区域化的程度 与事实上的NSTEMI区域化有关；(2)确定 分区后的非STEMI患者；(3)测量健康结局差异的变化 在弱势群体和普通人群之间。我们提出了一种方法，它利用了一系列自然的 加州的实验。使用加州全州卫生办公室的全州非公开数据 与生命统计相关的2006-2012年规划和发展(≈280,000名非STEMI患者) 死亡数据和由PI为父母赠款创建的STEMI注册表，我们将在- 用不同的方法确定区域化与治疗和治疗变化之间的联系 结果。 在目标1中，我们确定了区域化改变NSTEMI地点的程度 病人得到了他们的照顾。我们假设在经皮冠状动脉介入治疗中心接受NSTEMI治疗的比例增加 在区域化之后。在目标2中，我们确定NSTEMI患者的治疗和结果是否不同 在区域化社区内的介入治疗中心与非介入治疗中心治疗，以及结果 与区域化后的非区域化社区相比，区域化社区的患者情况有所改善。我们 假设冠状动脉介入治疗中心和区域化社区的结果有所改善。要了解如何 结果可能发生变化，我们还将测量NSTEMI患者接受经皮冠状动脉介入治疗的比例； 我们假设，这一比例也发生了类似的变化。在目标3中，我们将确定 与普通人群相比，弱势人群的治疗和结果不同，使用的是 差异法。我们假设不同群体之间的差距在 区域化。

PROJECT SUMMARY Coronary heart disease, including acute myocardial infarction (AMI), is the leading cause of death in the United States. Because ST-elevation myocardial infarctions (STEMIs) require timely access to percutaneous coronary intervention (PCI), many communities have created systems of regionalized STEMI care in which designated hospitals provide emergent PCI capability at all times. Regionalization is likely to have unintended consequences on non-STEMI (NSTEMI) care as patients and emergency medical services providers may increasingly seek care at PCI centers, and both PCI and non-PCI centers may change their care of NSTEMI patients. As NSTEMIs outnumber STEMIs by up to three to one and have a higher one-year mortality than STEMIs, understanding the impact of regionalization on NSTEMI care and outcomes is essential for policymakers and health systems if they choose to implement cardiac care regionalization. Our goals in this proposal are three-fold: (1) to determine the extent to which STEMI regionalization is associated with de facto NSTEMI regionalization; (2) to determine whether treatment and outcomes differed for NSTEMI patients after regionalization; and (3) to measure the changes in disparities of health outcomes between vulnerable and general populations. We propose an approach that exploits a series of natural experiments in California. Using statewide non-public data from the California Office of Statewide Health Planning and Development from 2006 through 2012 (≈280,000 NSTEMI patients) linked to Vital Statistics death data and a STEMI registry created by the PI for the parent grant, we will pursue a difference-in- differences approach to identify the association between regionalization and changes in treatment and outcomes. In Aim 1, we determine the extent to which regionalization changed the location at which NSTEMI patients received their care. We hypothesize that the proportion of NSTEMIs treated at PCI centers increased after regionalization. In Aim 2, we determine whether treatment and outcomes differed for NSTEMI patients treated at PCI centers versus non-PCI centers within regionalized communities, and whether outcomes improved for patients in regionalized compared to non-regionalized communities after regionalization. We hypothesize that outcomes improved at PCI centers and also in regionalized communities. To understand how changes in outcomes might occur, we will also measure the proportion of NSTEMI patients undergoing PCI; we hypothesize that this proportion changed similarly. In Aim 3, we will determine whether the changes in treatment and outcomes differed for vulnerable compared to general populations using a difference-in- difference-in-differences approach. We hypothesize that disparities between groups narrowed after regionalization.