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

探讨保险在 ST 段抬高型心肌梗死患者跨机构转运中的作用

• 批准号: 9813173
• 负责人: Michael J. Ward
• 金额: $ 12.75万
• 依托单位: VANDERBILT UNIVERSITY MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-07-01 至 2021-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9813173
• 关键词: Accident and Emergency department; Acute; Address; Affect; American; Biometry; California; Cardiology; Cardiovascular system; Caring; Congresses; County; Data; Data Set; Development; Emergency Care; Emergency Medicine; Emergency Situation; Emergency department visit; Ensure; Epidemiology; Health Insurance; Health Planning; Health Policy; Health Services Accessibility; Health Services Research; Healthcare; Hospitalization; Hospitals; Incidence; Insurance; Insurance Coverage; Intervention; Knowledge; Laws; Level of Evidence; Link; Location; Longitudinal trends; Medicaid; Medical; Medical emergency; Mental Health; Methodology; Methods; Modification; Myocardial Infarction; Myocardial Reperfusion; Natural experiment; Outcome; Patient Transfer; Patient-Focused Outcomes; Patients; Pattern; Play; Policies; Policy Maker; Prevalence; Probability; Quality of Care; Recommendation; Reperfusion Therapy; Research; Risk; Role; Science; Structure; System; Time; Time Management; Uninsured; United States; Work; design; disparity reduction; experience; health care disparity; high risk; innovation; multidisciplinary; optimal treatments; percutaneous coronary intervention; policy implication

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.

项目概要/摘要 在美国，每年有近 500,000 名患者患有 ST 段抬高型心肌梗死 (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 有能力进行初次经皮冠状动脉介入治疗（PCI），首选 心肌再灌注策略。因此，必须将患者转移到有能力的设施，这些设施 与近 90% 的患者的延误和患者预后较差有关。我们的研究团队有 确定保险状况是转移增加的关键非医疗预测因素。 STEMI 患者 与患者相比，缺乏保险到急诊室就诊的患者转院的可能性高出 60% 任何形式的保险。这一发现的两个潜在原因包括未投保的患者就诊 没有 PCI 能力的设施，或者，没有保险的患者被不必要地从 具有 PCI 功能的设施。 本研究的目的是确定导致不成比例的较高交互作用的根本机制。 未投保 STEMI 患者的设施转移率。未参保者获得保险的机会是否减少 支持 PCI 的设施，或者它们是从支持 PCI 的设施转移的，任一解释都很重要 减少这种对时间敏感的最佳管理的差距的政策影响 紧急医疗状况。我们已经确定了一个已建立的数据集，即全州卫生办公室 加利福尼亚州的规划和发展 (OSHPD) 数据集包含详细的 ED 就诊数据，这将使我们能够 确定更高传输率的根本机制。结合重要的卫生政策变化 扩大医疗保险覆盖范围，包括早期将 Medi-Cal 扩大到县级，这 提供了一个重要的自然实验，以了解保险的获取如何影响获得时间护理的机会- STEMI 等敏感紧急情况。 该提案描述了对现有数据集的分析，以了解更多患者的机制 患有 STEMI 的人缺乏保险并且转院率要高得多。具体目标是： 1) 描述 向加州急诊室就诊的 STEMI 患者的发病率、纵向趋势和转移状态 设施 PCI 能力； 2) 使用加州医疗补助扩展来估计保险之间的关系 向加州急诊室就诊的 STEMI 患者的状况和转诊情况，并评估 PCI 能力 修改这些关系。 我们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。我们预计知识 从中获得的信息将为政策制定者提供信息，以了解护理方面的差异，并了解是否 扩大保险范围是解决这些差异的潜在干预措施。