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

描述(申请人提供)：冠心病，包括急性心肌梗死(AMI)，是美国的主要死亡原因。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，及时接受经皮冠状动脉介入治疗(PCI)对患者的预后至关重要。为了改善STEMI患者的预后，美国各地在地方和州一级建立了STEMI区域化系统，以快速将STEMI患者路由或转移到 具有PCI功能的医院。然而，没有关于这一相对较新的医疗保健系统的研究能够表明区域化是否以及如何改善了社区一级的可及性和死亡率，因为以前的工作受到在单一医院环境中进行的研究的限制，只对某些过程结果进行评估，并且没有纳入一个对照小组来说明死亡率提高的长期趋势。我们在这项提案中的目标有三个：(1)确定区域化的STEMI系统在多大程度上与获取机会和结果的改善有关，(2)脆弱社区是否在同一系统中同等受益，以及(3)距离和时间如何不同地影响这些结果。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59%的县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方法，将加州全州卫生规划和发展办公室2006-2011年(H182,800名STEMI患者)的非公共患者出院数据与PI设计的每个县在同一时期的区域化状况数据库联系起来。在目标1中，我们将确定区域化和非区域化社区中STEMI患者的总体可获得性(通过进入有PCI能力的医院的入院定义)、治疗(接受PCI)和健康结果的差异程度。我们假设，在经历区域化的县中，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概率的变化将明显高于未区域化的县，并且健康结果将得到改善。在目标2中，我们将确定在获得、治疗和 STEMI患者在区域化社区与非区域化社区的结果发生了变化。我们假设，与参考人群相比，属于传统服务不足人群的STEMI患者在区域化后这些指标将有更大的改善。在目标3中，我们将根据区划后的距离和时间范围，确定STEMI患者在获取、治疗和结果方面的变化程度。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比那些居住在离区域冠状动脉介入治疗中心较近的患者受益更多，区域化的好处可能要到实施后1-2年才能看到。

DESCRIPTION (provided by applicant): 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 59% of its counties 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 between 2006-2011 (H182,800 STEMI patients) with a database designed by the PI of the 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.