Predictors of Ambulance Diversions: Do Hospitals Strategically Divert to Avoid Medicaid and Uninsured Patients

 描述(由申请人提供)：《紧急医疗和劳工法》(EMTALA)是联邦医疗保险的一项参与条件，要求医院为所有患者提供紧急护理，无论保险状态如何。医院可能会在怀疑救护车上有贫困患者时，策略性地暂时关闭急诊科(ED)，例如当附近的安全网医院正在改道时，从而绕过EMTALA。本文探讨了医院是否宣布这些“战略转移”，以及驱动这些转移的因素。由于医院试图选择经济上有利的患者组合，战略转移增加了不平等。此外，由于不必要地限制急救能力，战略性分流会威胁到所有患者的护理，因为急诊护理的延误会增加死亡率。这篇论文对AHRQ特别感兴趣，AHRQ旨在使医疗保健更安全、更容易获得和公平。该项目将实现三个目标。目标1是构建一个数据集，描述医院之间宣布改道的时间关系。该数据集结合了加利福尼亚州、ED的救护车分流日志数据和全州卫生规划和发展办公室的住院患者出院数据，以及美国医院协会年度调查的数据。目标2是检查医院是否进行了战略性转移。为了区分这些转移和必要的“容量驱动转移”，研究根据医院的规模和距离进行匹配，并使用具有医院随机效应的多变量Probit和Poisson来检查附近安全网和匹配的非安全网医院转移后的转移概率和特征。分流特征包括分流的时间长短和两家医院分别结束分流的间隔时间。主要的预测变量是附近医院的安全网状态，与影响急诊室拥挤和人员配备的变量相互作用，包括每天的急诊室占用率，并使用工具变量来解决对反向因果关系的担忧。目标3是探索影响医院是否宣布战略转移的因素，如组织文化和目标或转移的预期经济效益。它使用了与上面相同的分析，但增加了关于利润状况、医院提供的服务的盈利能力以及医院的医疗补助/未参保就诊的预测因子。

 DESCRIPTION (provided by applicant): The Emergency Medical Treatment and Labor Act (EMTALA), a condition of participation for Medicare, requires hospitals provide emergency care to all patients, regardless of insurance status. Hospitals may circumvent EMTALA by strategically temporarily closing their emergency departments (EDs) when they suspect ambulances contain indigent patients, such as when a nearby safety net hospital is on diversion. This dissertation explores whether hospitals declare these "strategic diversions," and the factors driving them. Strategic diversions increase inequities due to hospitals' attempts to select an economically favorable patient mix. Additionally, because they unnecessarily restrict ED capacity, strategic diversions threaten all patients' care since delays in ED care increase mortality. This dissertation is of particular interest to AHRQ, which aims to make health care safer, more accessible, and equitable. The project will address three aims. Aim 1 is to construct a dataset that describes the temporal relationship between hospitals declaring diversions. This dataset combines data from ambulance diversion logs in California, ED and inpatient discharge data from the Office of Statewide Health Planning and Development, and from the American Hospital Association Annual Survey. Aim 2 is to examine whether hospitals engage in strategic diversions. To distinguish between these diversions and necessary, "capacity-driven diversions," the study matches hospitals by size and distance, and uses multivariate probit and poisson with hospital random effects to examine diversion probability and characteristics after nearby safety net and matched non-safety net hospitals divert. Diversion characteristics include length of diversion and time elapsing between when the two hospitals end their respective diversions. The main predictor variables are the safety net status of the nearby hospital interacted with variables operationalizing ED crowding and staffing, including daily ED occupancy, and uses instrumental variables to address concerns about reverse causality. Aim 3 is to explore factors that influence whether hospitals declare strategic diversions, such as organizational culture and goals or the anticipated economic benefit of diverting. It uses the same analyses above but adds predictors about profit status, the profitability of services offered by the hospital, and the Medicaid/uninsured visits at the hospital.