Disruptions in ST-Elevation Myocardial Infarction Transfer Networks and Cardiovascular Health of Rural Americans

项目摘要 美国农村地区面临着不成比例的心血管疾病负担，但他们必须走得更远才能到达 能够为急性心肌梗死（AMI）提供有效、符合指南的治疗的医院。 转移网络在农村ST段抬高型心肌梗死（STEMI）的护理中发挥着至关重要的作用， 严重的急性心肌梗死，将患者从农村医院转移到可以进行初级经皮穿刺的医院。 冠状动脉介入治疗（PCI）是STEMI的首选治疗方法。在925家医院中， 自2007年以来，在农村地区获得的，75%可能是ST段抬高型心肌梗死转移网络的一部分。虽然封闭 医院的收购可能会破坏STEMI转移网络，对STEMI患者的影响尚未得到 探讨了现有的关于医院关闭的研究发现了关于AMI死亡率的相互矛盾的结果。无法考虑 网络在三个方面对以前的研究不利。1)PCI时间取决于地理位置， ST段抬高型心肌梗死转移网络中医院的转移关系。2)干扰可能导致溢出 对病人的影响不直接受关闭和收购的影响，但在同一个转移网络。3)的 网络特性影响中断后PCI的时间。虽然以前没有探讨过， 农村STEMI网络可能会加剧AMI死亡率的城乡差异， 农村心血管疾病死亡率在过去的四十年里。该项目将利用新的数据资源 研究小组收集的数据，包括关于医院关闭状态和时间的经验证的数据， 关于医院级PCI能力的数据。利用研究团队的专业知识， 分析技术，侵入性心脏病学，急诊医学，农村健康，医疗保险索赔数据，以及 我们将使用2007 - 2021年的医疗保险索赔数据估计STEMI转移网络，并链接 网络到医院关闭和采集数据收集和验证的研究小组。我们将 利用与STEMI护理和农村卫生系统利益相关者的联系以及调查方面的专业知识 设计并实施对EMS机构的调查，以收集紧急情况信息 STEMI网络中的医疗服务参与。我们提出以下目标：1）估计关联 ST段抬高型心肌梗死（STEMI）网络中断与PCI通过网络时间的关系; 2）估计STEMI网络与PCI的关联 ST段抬高型心肌梗死治疗中断和死亡率; 3）确定与 STEMI网络中断后的患者死亡率;以及4）量化STEMI传输网络中断的作用 城乡STEMI差异。我们将传播有关STEMI网络及其特征的信息 我们的研究结果将为农村患者确定一个以前未知的访问障碍， 告知政策制定者和临床医生如何改善农村STEMI患者的健康。

PROJECT ABSTRACT Rural Americans face disproportionate cardiovascular disease burden, yet they must travel farther to reach hospitals that can provide effective, guideline-concordant treatment for acute myocardial infarction (AMI). Transfer networks play a crucial role in care for rural ST-Elevation Myocardial Infarction (STEMI), the most severe form of AMI, moving patients from rural hospitals to hospitals that can perform primary Percutaneous Coronary Intervention (PCI), the preferred treatment for STEMI. Of the 925 hospitals have closed or been acquired in rural areas since 2007, 75% may have been part of a STEMI transfer network. Although closures and acquisitions of hospitals may disrupt STEMI transfer network, the impact on STEMI patients has not been explored. Existing research on hospital closures finds conflicting results on AMI mortality. Failure to account for networks disadvantages previous research in 3 ways. 1) Time to PCI depends on the geographic location and the transfer relationships of hospitals within STEMI transfer networks. 2) Disruptions can cause spillover effects to patients not directly affected by closures and acquisitions but in the same transfer network. 3) The characteristics of network affect time to PCI after disruption. Although not previously explored, disruptions in rural STEMI networks could worsen rural-urban disparities in AMI mortality rates and reverse reductions in rural cardiovascular mortality over the past four decades. This project will draw upon novel data resources collected by the research team including validated data on hospital closure status and timing and validated data on hospital-level PCI capabilities. Leveraging the expertise of the research team in innovative network analysis techniques, invasive cardiology, emergency medicine, rural health, Medicare claims data, and biostatistics we will estimate STEMI transfer networks using Medicare claims data from 2007-2021 and link networks to hospital closure and acquisition data collected and validated by the research team. We will leverage connections to stakeholders in STEMI systems of care and rural health as well as expertise in survey design and implementation to develop a survey of EMS agencies to collect information on the emergency medical services involvement in STEMI networks. We propose the following aims: 1) estimate the association of STEMI network disruption with through0network time to PCI; 2) estimate the association of STEMI network disruption with STEMI treatment and mortality; 3) identify network-level factors associated with changes in patient mortality after STEMI network disruption; and 4) quantify the role of STEMI transfer network disruption in rural-urban STEMI disparities. We will disseminate information on STEMI networks and their characteristics via a web-based app. Our findings will identify a previously unknown access barrier for rural patients and can inform policymakers and clinicians about how to improve the health of rural STEMI patients.