Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention

17 USC 105 interim-entered record; under review.The article of record as published may be found at http://dx.doi.org/10.1111/acem.14195Background. Patients with ST-elevation myocardial infarction (STEMI) require timely reperfusion, and percutaneous coronary intervention (PCI) decreases morbidity and mortality. Regionalization of STEMI care has increased timeliness and use of PCI, but it is unknown whether benefits to regionalization depend on a community's distance from its nearest PCI center. We sought to determine whether STEMI regionalization benefits, measured by access to PCI centers, timeliness of treatment (same-day or in-hospital PCI), and mortality, differ by baseline distance to nearest PCI center. Methods. Using a difference-in-difference-in-differences model, we examined access to PCI-capable hospitals, receipt of PCI either on the day of admission or during the care episode, and health outcomes for patients hospitalized from January 1, 2006, to September 30, 2015. Results. Of 139,408 patients (2006 to 2015), 51% could reach the nearest PCI center in <30 minutes, and 49% required ≥30 minutes driving time. For communities with baseline access ≥30 minutes, regionalization increased the probability of admission to a PCI-capable hospital by 9.4% and also increased the likelihood of receiving same-day PCI (by 11.2%) and PCI during the hospitalization (by 7.4%). Patients living within 30 minutes did not accrue significant benefits (measured by admission to a PCI-capable hospital or receipt of PCI) from regionalization initiatives. Regionalization more than halved access disparities and completely eliminated treatment disparities between communities ≥30 minutes and communities <30 minutes from the nearest PCI hospital. Conclusions. Measured by likelihood of admission to a PCI-capable facility and receipt of PCI, benefits of STEMI regionalization in California accrued only to patients whose nearest PCI center was ≥30 minutes away. We found no mortality benefits of regionalization based on distance from PCI center. Our results suggest that policymakers focus STEMI regionalization efforts in communities that are not already well serviced by PCI-capable hospitals

Emergency Department Closures And Openings: Spillover Effects On Patient Outcomes In Bystander Hospitals

The article of record as published may be found at http://dx.doi.org/10.1377/hlthaff.2019.00125High-occupancy hospitals may be sensitive to neighboring emergency department (ED) closures and openings, as they already operate at or near capacity. We conducted a retrospective analysis using data for the period 2001-13 to examine outcomes of and treatment received by patients with acute myocardial infarction at so-called bystander EDs that had been exposed to nearby ED closures or openings. We used changes in driving time between an ED and the next-closest one as a proxy for a closure or opening: If driving time increased, for instance, it meant that a nearby ED had closed. When a high-occupancy ED was exposed to a closure that resulted in increased driving time of thirty minutes or more to the next-closest ED, one-year mortality and thirty-day readmission rates increased by 2.39 and 2.00 percentage points, respectively, while the likelihood of receiving percutaneous coronary intervention (PCI) declined by 2.06 percentage points. Exposure to ED openings that resulted in decreased driving times of thirty minutes or more was associated with reductions in thirty-day mortality at bystander hospitals and an increased likelihood of receiving PCI. Our findings suggest that limited resources at high-occupancy bystander hospitals make them sensitive to changes in the availability of emergency care in neighboring communities.This work was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (Grant Nos. R01HL114822 and R01HL134182 to both Renee Hsia and Yu-Chu Shen).This work was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (Grant Nos. R01HL114822 and R01HL134182 to both Renee Hsia and Yu-Chu Shen)

Association Between Emergency Department Closure and Treatment, Access, and Health Outcomes Among Patients With Acute Myocardial Infarction

The article of record as published may be found at https://doi.org/10.1161/CIRCULATIONAHA.116.025057Within the past 2 decades, the annual number of emergency department (ED) visits increased >40%, but the number of EDs decreased by 11%.1 The closure of an ED can have a profound effect on a community,2–5 because patients have to drive farther to obtain care, and the remaining EDs have to bear the extra patient volume, especially for patients experiencing time-sensitive illnesses requiring prompt intervention, such as acute myocardial infarction.This research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Grant Award Number R01HL114822, and by the American Heart Association under Grant Award Number 13CRP14660029

Does Decreased Access to Emergency Departments Affect Patient Outcomes? Analysis of AMI Population 1996-2005

We analyze whether decreased emergency department access (measured by increased driving time to the nearest ED) results in adverse patient outcomes or changes in the patient health profile for patients suffering from acute myocardial infarction. Data sources include 100% Medicare Provider Analysis and Review, AHA hospital annual surveys, Medicare hospital cost reports, and longitude and latitude information for 1995-2005. We define four ED access change categories and estimate a zip codes fixed-effects regression models on the following AMI outcomes: time-specific mortality rates, age, and probability of PTCA on the day of admission. We find a small increase in 30-day to 1-year mortality rates among patients in communities that experience 30-minute increases in driving time, we find a substantial increase in long-term mortality rates, a shift to younger ages (suggesting that the older ones die en route) and a higher probability of immediate PTCA. Most of the adverse effects disappear after the initial three-year transition window.

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study

This is the publisher's version. To view the original publication, see http://bmjopen.bmj.comThis article aims to examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). Hospital charges and discounted prices were adjusted for each patient's clinical and demographic characteristics. We analysed 76,766 vaginal deliveries and 32,660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3,296 or as much as US$37,227 for a vaginal delivery and US$8,312–US$70,908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35–36% of the between-hospital variation in charges. These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups—uncomplicated vaginal delivery and caesarean section—vary widely between hospitals and are not well explained by observable patient or hospital characteristics

Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017

The article of record as published may be located at https://doi.org/10.1001/jamanetworkopen.2019.7855Objective: To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. Design, Setting, and Participants: This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non–stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. Main Outcomes and Measures: Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. Results The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). Conclusions and Relevance: This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification

Ten-year trends in traumatic brain injury: a retrospective cohort study of California emergency department and hospital revisits and readmissions.

OBJECTIVE:To describe visits and visit rates of adults presenting to emergency departments (EDs) with a diagnosis of traumatic brain injury (TBI). TBI is a major cause of death and disability in the USA; yet, current literature is limited because few studies examine longer-term ED revisits and hospital readmission patterns of TBI patients across a broad spectrum of injury severity, which can help inform potential unmet healthcare needs. DESIGN:We performed a retrospective cohort study. SETTING:We analysed non-public patient-level data from California's Office of Statewide Health Planning and Development for years 2005 to 2014. PARTICIPANTS:We identified 1.2 million adult patients aged ≥18 years presenting to California EDs and hospitals with an index diagnosis of TBI. PRIMARY AND SECONDARY OUTCOME MEASURES:Our main outcomes included revisits, readmissions and mortality over time. We also examined demographics, mechanism and severity of injury and disposition at discharge. RESULTS:We found a 57.7% increase in the number of TBI ED visits, representing a 40.5% increase in TBI visit rates over the 10-year period (346-487 per 100 000 residents). During this time, there was also a 33.8% decrease in the proportion of patients admitted to the hospital. Older, publicly insured and black populations had the highest visit rates, and falls were the most common mechanism of injury (45.5% of visits). Of all patients with an index TBI visit, 40.5% of them had a revisit during the first year, with 46.7% of them seeking care at a different hospital from their initial hospital or ED visit. Additionally, of revisits within the first year, 13.4% of them resulted in hospital readmission. CONCLUSIONS:The large proportion of patients with TBI who are discharged directly from the ED, along with the high rates of revisits and readmissions, suggest a role for an established system for follow-up, treatment and care of TBI

Trends in the utilisation of emergency departments in California, 2005-2015: a retrospective analysis.

ObjectiveTo examine current trends in the characteristics of patients visiting California emergency departments (EDs) in order to better direct the allocation of acute care resources.DesignA retrospective study.SettingWe analysed ED utilisation trends between 2005 and 2015 in California using non-public patient data from California's Office of Statewide Health Planning and Development.ParticipantsWe included all ED visits in California from 2005 to 2015.Primary and secondary outcome measuresWe analysed ED visits and visit rates by age, sex, race/ethnicity, payer and urban/rural trends. We further examined age, sex, race/ethnicity and urban/rural trends within each payer group for a more granular picture of the patient population. Additionally, we looked at the proportion of patients admitted from the ED and distribution of diagnoses.ResultsBetween 2005 and 2015, the annual number of ED visits increased from 10.2 to 14.2 million in California. ED visit rates increased by 27.8% (p&lt;0.001), with the greatest increases among patients aged 5-19 (37.4%, p&lt;0.001) and 45-64 years (41.1%, p&lt;0.001), non-Hispanic Black and Hispanic patients (56.8% and 48.8%, p&lt;0.001), the uninsured and Medicaid-insured (36.1%, p=0.002; 28.6%, p&lt;0.001) and urban residents (28.3%, p&lt;0.001). The proportion of ED visits resulting in hospitalisation decreased by 18.3%, with decreases across all payer groups.ConclusionsOur findings reveal an increasing demand for emergency care and may reflect current limitations in accessing care in other parts of the healthcare system. Policymakers may need to recognise the increasingly vital role that EDs are playing in the provision of care and consider ways to incorporate this changing reality into the delivery of health services

Variation in charges for 10 common blood tests in California hospitals: A cross-sectional analysis

Objectives: To determine the variation in charges for 10 common blood tests across California hospitals in 2011, and to analyse the hospital and market-level factors that may explain any observed variation. Design setting and participants: We conducted a cross-sectional analysis of the degree of charge variation between hospitals for 10 common blood tests using charge data reported by all non-federal California hospitals to the California Office of Statewide Health Planning and Development in 2011. Outcome measures: Charges for 10 common blood tests at California hospitals during 2011. Results: We found that charges for blood tests varied significantly between California hospitals. For example, charges for a lipid panel ranged from US$10 to US$10 169, a thousand-fold difference. Although government hospitals and teaching hospitals were found to charge significantly less than their counterparts for many blood tests, few other hospital characteristics and no market-level predictors significantly predicted charges for blood tests. Our models explained, at most, 21% of the variation between hospitals in charges for the blood test in question. Conclusions: These findings demonstrate the seemingly arbitrary nature of the charge setting process, making it difficult for patients to act as true consumers in this era of ‘consumer-directed healthcare.