Examining the role of insurance in inter-facility transfer for patients with ST-elevation myocardial infarction

项目摘要/摘要 在美国，每年有近50万患者患有ST段抬高心肌梗死(STEMI)。 其中大部分最初提交给急诊科(ED)。超过60%的美国医院没有 有能力进行直接经皮冠状动脉介入治疗(PCI)，首选 心肌再灌注的策略。因此，病人必须被转移到有能力的设施，这些设施 与近90%的患者延误和更糟糕的患者结局相关。我们的研究团队已经 确定保险状况是转移增加的一个关键的非医疗预测因素。STEMI患者谁 向急诊室提交的缺乏保险的患者被转移的可能性比患者高60% 任何形式的保险。这一发现的两个潜在原因包括未参保的患者出现在 没有PCI功能的设施，或者，没有保险的患者被不必要地从 具有PCI功能的设施。 这项研究的目的是找出导致不成比例的相互作用的潜在机制。 未参保的STEMI患者的设施转移率。未参保的人是否减少了获得 支持PCI的设施，或者它们是从支持PCI的设施转移过来的，这两种解释都很重要 减少这一时间敏感型工作的最佳管理机会方面的差距所涉政策问题 紧急医疗状况。我们已经确定了一个已建立的数据集，全州卫生办公室 加州规划与发展(OSHPD)数据集，其中包含详细的ED访问数据，这将使我们能够 确定更高传输率的潜在机制。结合重要的卫生政策变化 扩大医疗保险渠道，包括早期在县级扩大Medi-Cal，这 提供了一个重要的自然实验，以了解保险获取如何影响护理时间的获取- 像STEMI这样的敏感紧急情况。 这项建议描述了对现有数据集的分析，以了解更多患者的发病机制 没有保险的STEMI患者的转移率要高得多。具体目标是：1)描述 在加州急诊室就诊的STEMI患者的发病率、纵向趋势和转移状态 设施PCI功能；2)使用加州的Medicaid扩展来评估保险之间的关系 向加州急诊室就诊的STEMI患者的状态和转院情况，并评估是否有经皮冠状动脉介入治疗的能力 修改这些关系。 我们已经组建了一支由心脏病学、急诊医学、卫生政策、 卫生服务研究、生物统计学、流行病学和系统科学。我们预计，这些知识 从中获得的信息将为寻求了解医疗保健差异的政策制定者提供信息，并了解 保险扩张是解决这些差距的一种潜在干预措施。

PROJECT SUMMARY/ABSTRACT In the U.S., nearly 500,000 patients suffer an ST-elevation myocardial infarction (STEMI) each year, the majority of which initially present to emergency departments (EDs). More than 60% of U.S. hospitals do not have have the capabilities to perform the primary percutaneous coronary intervention (PCI), the preferred strategy for myocardial reperfusion. Thus, patients must be transferred to capable facilities which are associated with delays for nearly 90% of patients and worse patient outcomes. Our research team has identified that insurance status is a key non-medical predictor of increased transfer. Patients with STEMI who lack insurance presenting to the ED were 60% more likely to be transferred compared with patients with any form of insurance. Two potential reasons for this finding include uninsured patients presenting to facilities without PCI capabilities and alternatively, uninsured patients being transferred unnecessarily from facilities that have PCI capabilities. The objective of this study is to identify the underlying mechanism resulting in disproportionately higher inter- facility transfer rates for uninsured patients with STEMI. Whether the uninsured have diminished access to PCI-capable facilities, or they are transferred from PCI-capable facilities, either explanation has important policy implications for reducing this disparity in access to optimal management of this time-sensitive emergency medical condition. We have identified an established dataset, the Office of Statewide Health Planning and Development (OSHPD) dataset in California which has detailed ED visit data which will allow us identify the underlying mechanism of higher transfer rates. Combined with important health policy changes broadening health insurance access including the early expansion of Medi-Cal at the county-level, this provides an important natural experiment to understand how insurance access affects access to care for time- sensitive emergencies like STEMI. This proposal describes an analysis of the existing datasets to understand the mechanism of more patients with STEMI who lack insurance and are transferred at a much higher rate. The Specific Aims are: 1) Describe the incidence, longitudinal trends, and transfer status of patients with STEMI presenting to California EDs by facility PCI capability; 2) Use Medicaid expansion in California to estimate the relationship between insurance status and transfer of patients presenting to California EDs with STEMI, and assess whether PCI capability modifies these relationships. We have assembled a multidisciplinary team of experts in cardiology, emergency medicine, health policy, health services research, biostatistics, epidemiology, and systems science. We anticipate that the knowledge gained from this will inform policy makers seeking to understand disparities in care, and to understand whether insurance expansion is a potential intervention to address these disparities.