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

项目摘要 冠心病，包括急性心肌梗死（AMI），是导致死亡的主要原因， 美国的由于ST段抬高型心肌梗死（STEMI）需要及时进入经皮 冠状动脉介入治疗（PCI），许多社区已经建立了区域化STEMI护理系统， 指定医院随时提供紧急PCI能力。区域化可能会产生意想不到的 对非STEMI（NSTEMI）护理的后果，因为患者和紧急医疗服务提供者可能 越来越多的人在PCI中心寻求治疗，PCI和非PCI中心都可能改变他们对NSTEMI的治疗 患者由于NSTEMI的数量超过STEMI高达三比一，并且一年死亡率高于 STEMI，了解区域化对NSTEMI护理和结局的影响至关重要， 决策者和卫生系统，如果他们选择实施心脏护理区域化。 我们在这项提案中的目标有三个方面：（1）确定STEMI区域化的程度， 与事实上的NSTEMI区域化相关;（2）确定治疗和结局是否与 区域化后NSTEMI患者;（3）测量健康结果差异的变化 脆弱人群和普通人群之间的差异。我们提出了一种方法，利用一系列自然的 在加州做实验。使用来自加州全州健康办公室的全州非公开数据 2006年至2012年的规划和发展（280，000名NSTEMI患者）与生命统计数据有关 死亡数据和由PI为父母补助金创建的STEMI登记处，我们将追求差异- 差异方法，以确定区域化与治疗变化之间的关联， 结果。 在目标1中，我们确定区域化在多大程度上改变了NSTEMI的位置。 病人得到了他们的照顾。我们假设在PCI中心接受治疗的NSTEMI比例增加 区域化后。在目标2中，我们确定NSTEMI患者的治疗和结局是否不同 在区域化社区内PCI中心与非PCI中心治疗，以及结果 区域化后，与非区域化社区相比，区域化社区的患者得到改善。我们 假设PCI中心和区域化社区的结果得到改善。了解如何 结果可能发生的变化，我们还将测量接受PCI的NSTEMI患者的比例; 我们假设这一比例也发生了类似变化。在目标3中，我们将确定 与一般人群相比，弱势群体的治疗和结局不同， 差异中的差异方法。我们假设，群体之间的差距缩小后， 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.