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

项目总结/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ST段抬高型心肌梗死（STEMI）是一种常见且特别严重的AMI形式， 及时进行经皮冠状动脉介入治疗（PCI）对患者的良好预后至关重要。中 为了改善STEMI患者的结局，STEMI区域化系统已在 美国各地的地方和州一级，以快速路由或转移STEMI患者到PCI医院 能力。然而，对于这种相对较新的医疗保健系统，没有任何研究能够表明是否以及如何 区域化改善了社区一级的获得机会和死亡率，因为以前的工作受到以下因素的限制： 在单一医院环境中进行的研究，仅对某些过程结果进行评价， 纳入一个对照组，以说明死亡率改善的长期趋势。 我们在本提案中的目标有3个方面：（1）确定区域化STEMI系统在多大程度上 与获得和结果的改善相关，（2）弱势社区是否受益 同样在同一系统内，以及（3）距离和时间如何不同地影响这些结果。到 为了实现这些目标，我们提出了一个创新的和明确的方法来研究加州，一个国家， 提供了STEMI区域化的自然实验，因为其47%的人口居住在 在研究期间的不同时间进行了区域化。我们将采用差异化的方法， 链接来自加州全州卫生规划和发展办公室的非公开患者出院数据 2006年至2012年（约90 K STEMI患者），由PI设计的区域化状态数据库， 在同一时期的每个县。在目标1中，我们将确定总体访问（定义为 入院接受PCI的医院）、治疗（接受PCI）和健康结局对于STEMI患者不同 在区域化和非区域化的社区中。我们假设， 接受PCI设备的医院和接受PCI的人数在经历PCI的县中会明显增加。 区域化的国家比非区域化的国家多，健康结果将得到改善。在目标2中，我们 确定STEMI患者在获取、治疗和结局方面的差异发生变化的程度 在区域化和非区域化的社区中。我们假设属于以下类型的STEMI患者 传统上服务不足的人口在区域化后在这些指标上将有更大的改善 相对于参考人群。在目标3中，我们将确定在多大程度上改变访问， STEMI患者的治疗和结局根据以下距离和时间范围而不同 区域化。我们假设居住在远离区域PCI中心的STEMI患者将受益 差异比那些生活在更接近区域PCI中心的人更多，区域化的好处可能不会 直到实施后的1-2年。

PROJECT SUMMARY/ABSTRACT Coronary heart disease, including acute myocardial infarction (AMI), is the leading cause of death in the United States. ST-elevation myocardial infarction (STEMI) is a common and particularly severe form of AMI for which timely access to percutaneous coronary intervention (PCI) is essential to good patient outcomes. In an attempt to improve outcomes for STEMI patients, STEMI regionalization systems have been established at the local and state level across the United States to quickly route or transfer STEMI patients to a hospital with PCI capability. However, no studies of this relatively new healthcare system have been able to show if and how regionalization has improved access and mortality at the community level, as prior work has been limited by studies done in single-hospital settings, the evaluation of only certain process outcomes, and the lack of inclusion of a control group to account for secular trends in improved mortality. Our goals in this proposal are 3-fold: (1) to determine to what extent regionalized STEMI systems are associated with improvements in both access and outcomes, (2) whether vulnerable communities benefit equally within the same system, and (3) how distance and time differentially affect these outcomes. To accomplish these goals, we propose an innovative and definitive approach to study California, a state that provides a natural experiment of STEMI regionalization, as 47% of its population has resided in counties that have regionalized at different times over the study period. We will use a difference-in-differences approach and link non-public patient discharge data from the California Office of Statewide Health Planning and Development from 2006 through 2012 (≈90K STEMI patients) with a database designed by the PI of regionalization status of each county over the same period. In Aim 1, we will determine the extent to which overall access (defined by admission to PCI-capable hospital), treatment (receipt of PCI), and health outcomes differ for STEMI patients in regionalized vs. non-regionalized communities. We hypothesize that the change in probability of being admitted to a PCI-equipped hospital and of receiving PCI will be appreciably higher in counties experiencing regionalization than non-regionalized counties and that health outcomes will improve. In Aim 2, we will determine the extent to which disparities in access, treatment, and outcomes have changed for STEMI patients in regionalized vs. non-regionalized communities. We hypothesize that STEMI patients who belong to traditionally underserved populations will have larger improvements in these metrics post-regionalization relative to the reference population. In Aim 3, we will determine the extent to which changes in access, treatment, and outcome differ for STEMI patients according to distance and time horizon following regionalization. We hypothesize that STEMI patients living farther away from regional PCI centers will benefit differentially more than those living closer to regional PCI centers, and benefits of regionalization may not be seen until 1-2 years post-implementation.