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

项目摘要/摘要 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。ST段抬高心肌梗死(STEMI)是一种常见且特别严重的急性心肌梗死 能否及时获得经皮冠状动脉介入治疗(PCI)对患者的良好预后至关重要。在一个 为了改善STEMI患者的预后，STEMI地区化系统已经在 在全美的地方和州级快速将STEMI患者路由或转送到使用经皮冠状动脉介入治疗的医院 能力。然而，还没有关于这种相对较新的医疗保健系统的研究能够表明是否以及如何 区域化改善了社区一级的可及性和死亡率，因为以前的工作受到以下限制 在单一医院环境下进行的研究，只评估某些过程结果，以及缺乏 纳入一个对照组，以说明死亡率提高的长期趋势。 我们在这项建议中的目标有三个：(1)确定STEMI系统的区域化程度 与获得机会和成果的改善有关，(2)弱势社区是否受益 (3)距离和时间如何不同地影响这些结果。至 为了实现这些目标，我们提出了一种创新和明确的方法来研究加州，该州 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。我们将使用差异中的差异方法和 链接加州全州卫生规划和发展办公室的非公共病人出院数据 2006年至2012年(≈9万名STEMI患者)与PI设计的数据库的区域化状况 每个县都在同一时期。在目标1中，我们将确定总体访问的程度(由 STEMI患者入院)、治疗(接受PCI)和健康结局不同 在区域化社区与非区域化社区之间。我们假设存在的概率的变化 入院接受经皮冠状动脉介入治疗的医院和接受经皮冠状动脉介入治疗的县将明显更高 他说，与未进行区域化的县相比，实行区域化将会更好，健康结果将会有所改善。在目标2中，我们将 确定STEMI患者在获取、治疗和结果方面的差异改变的程度 在区域化社区与非区域化社区之间。我们假设STEMI患者属于 传统上服务不足的人群在区域化后将在这些指标上有更大的改善 相对于参考人口。在目标3中，我们将确定准入方面的变化程度， STEMI患者的治疗和结果因距离和时间范围的不同而不同 区域化。我们假设STEMI患者居住在离区域冠状动脉介入治疗中心较远的地方将受益 与那些居住在离地区PCI中心更近的人相比，差异更大，区域化的好处可能不会 直到实施后1-2年才能看到。

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.