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

项目摘要 美国农村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。 转院网络在农村ST段抬高心肌梗死(STEMI)的护理中发挥着至关重要的作用，其中 严重的急性心肌梗死，将患者从乡村医院转移到可以进行直接经皮穿刺术的医院 冠状动脉介入治疗(PCI)，STEMI的首选治疗方法。在925家医院中，已关闭或 自2007年以来在农村地区获得的75%可能是STEMI转移网络的一部分。尽管闭包 而收购医院可能会扰乱STEMI的转移网络，对STEMI患者的影响尚未得到 探索过了。现有的关于关闭医院的研究发现，关于急性心肌梗死死亡率的结果相互矛盾。未能说明原因 网络在三个方面削弱了之前的研究。1)介入治疗的时间取决于地理位置和 STEMI转运网络内医院的转运关系。2)中断可能会导致溢出 对患者的影响不直接受关闭和收购的影响，但在相同的转送网络中。3) 网络特性会影响中断后的PCI时间。尽管之前没有探索过，但 农村STEMI网络可能会恶化急性心肌梗死死亡率的城乡差异，并逆转 过去40年农村心血管疾病死亡率。该项目将利用新的数据资源 由研究团队收集，包括关于医院关闭状态和时间的验证数据，以及 有关医院级PCI功能的数据。利用研究团队在创新网络方面的专业知识 分析技术、侵入性心脏病学、急救医学、农村卫生、医疗保险索赔数据，以及 生物统计学我们将使用2007-2021年的联邦医疗保险索赔数据估计STEMI转移网络，并链接 由研究小组收集和验证医院关闭和获取数据的网络。我们会 利用与STEMI保健和农村卫生系统中的利益攸关方的联系以及调查方面的专业知识 设计和实施对EMS机构进行调查，以收集紧急情况的信息 医疗服务参与STEMI网络。我们提出了以下目标：1)估计关联度 STEMI网络中断与到PCI的网络通过时间的关系；2)估计STEMI网络的关联 STEMI治疗的中断和死亡率；3)确定与STEMI治疗的变化相关的网络层面因素 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差距。我们将传播关于STEMI网络及其特点的信息 通过一个基于网络的应用程序。我们的发现将确定农村患者以前未知的准入障碍，并可以 告知决策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.