Yu-Chu Shen1,2, Harlan Krumholz3,4,5, Renee Y Hsia6,7. 1. Graduate School of Defense Management, Naval Postgraduate School (Y.-C.S.). 2. National Bureau of Economic Research (Y.-C.S.). 3. Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine (H.K.). 4. Department of Health Policy and Management, Yale School of Public Health (H.K.). 5. Center for Outcomes Research and Evaluation, Yale-New Haven Hospital (H.K.). 6. Department of Emergency Medicine (R.Y.H.), University of California at San Francisco. 7. Philip R. Lee Institute for Health Policy Studies (R.Y.H.), University of California at San Francisco.
Abstract
BACKGROUND: Regionalization of ST-segment elevation myocardial infarction (STEMI) systems of care has been championed over the past decade. Although timely access to percutaneous coronary intervention (PCI) has been shown to improve outcomes, no studies have determined how regionalization has affected the care and outcomes of patients. We sought to determine if STEMI regionalization is associated with changes in access, treatment, and outcomes. METHODS: Using a difference-in-differences approach, we analyzed a statewide, administrative database of 139 494 patients with STEMI in California from 2006 to 2015 using regionalization data based on a survey of all local Emergency Medical Services agencies in the state. RESULTS: For patients with STEMI, the base rate of admission to a hospital with PCI capability was 72.7%, and regionalization was associated with an increase of 5.34 percentage points (95% CI, 1.58-9.10), representing a 7.1% increase. Regionalization was also associated with a statistically significant increase of 3.54 (95% CI, 0.61-6.48) percentage points in the probability of same-day PCI, representing an increase of 7.1% from the 49.7% base rate and a 4.6% relative increase (2.97 percentage points [95% CI, 0.1-5.85]) in the probability of receiving PCI at any time during the hospitalization. There was a 1.84 percentage point decrease (95% CI, -3.31 to -0.37) in the probability of receiving fibrinolytics. For 7-day mortality, regionalization was associated with a 0.53 (95% CI, -1 to -0.06) percentage point greater reduction (representing 5.8% off the base rate of 9.1%) and a 1.75 percentage point decrease in the likelihood of all-cause 30-day readmission (95% CI, -3.39 to -0.11; representing 6.4% off the base rate of 27.4%). No differences were found in longer-term mortality. CONCLUSIONS: Among patients with STEMI in California from 2006 to 2015, STEMI regionalization was associated with increased access to a PCI-capable hospital, greater use of PCI, lower 7-day mortality, and lower 30-day readmissions.
BACKGROUND: Regionalization of ST-segment elevation myocardial infarction (STEMI) systems of care has been championed over the past decade. Although timely access to percutaneous coronary intervention (PCI) has been shown to improve outcomes, no studies have determined how regionalization has affected the care and outcomes of patients. We sought to determine if STEMI regionalization is associated with changes in access, treatment, and outcomes. METHODS: Using a difference-in-differences approach, we analyzed a statewide, administrative database of 139 494 patients with STEMI in California from 2006 to 2015 using regionalization data based on a survey of all local Emergency Medical Services agencies in the state. RESULTS: For patients with STEMI, the base rate of admission to a hospital with PCI capability was 72.7%, and regionalization was associated with an increase of 5.34 percentage points (95% CI, 1.58-9.10), representing a 7.1% increase. Regionalization was also associated with a statistically significant increase of 3.54 (95% CI, 0.61-6.48) percentage points in the probability of same-day PCI, representing an increase of 7.1% from the 49.7% base rate and a 4.6% relative increase (2.97 percentage points [95% CI, 0.1-5.85]) in the probability of receiving PCI at any time during the hospitalization. There was a 1.84 percentage point decrease (95% CI, -3.31 to -0.37) in the probability of receiving fibrinolytics. For 7-day mortality, regionalization was associated with a 0.53 (95% CI, -1 to -0.06) percentage point greater reduction (representing 5.8% off the base rate of 9.1%) and a 1.75 percentage point decrease in the likelihood of all-cause 30-day readmission (95% CI, -3.39 to -0.11; representing 6.4% off the base rate of 27.4%). No differences were found in longer-term mortality. CONCLUSIONS: Among patients with STEMI in California from 2006 to 2015, STEMI regionalization was associated with increased access to a PCI-capable hospital, greater use of PCI, lower 7-day mortality, and lower 30-day readmissions.
Authors: Timothy D Henry; Scott W Sharkey; M Nicholas Burke; Ivan J Chavez; Kevin J Graham; Christopher R Henry; Daniel L Lips; James D Madison; Katie M Menssen; Michael R Mooney; Marc C Newell; Wes R Pedersen; Anil K Poulose; Jay H Traverse; Barbara T Unger; Yale L Wang; David M Larson Journal: Circulation Date: 2007-08-01 Impact factor: 29.690
Authors: Henry H Ting; Charanjit S Rihal; Bernard J Gersh; Luis H Haro; Christine M Bjerke; Ryan J Lennon; Choon-Chern Lim; John F Bresnahan; Allan S Jaffe; David R Holmes; Malcolm R Bell Journal: Circulation Date: 2007-08-01 Impact factor: 29.690
Authors: Daniel S Menees; Eric D Peterson; Yongfei Wang; Jeptha P Curtis; John C Messenger; John S Rumsfeld; Hitinder S Gurm Journal: N Engl J Med Date: 2013-09-05 Impact factor: 91.245
Authors: Seth W Glickman; Melissa A Greiner; Li Lin; Lesley H Curtis; Charles B Cairns; Christopher B Granger; Eric D Peterson Journal: Ann Emerg Med Date: 2011-08-20 Impact factor: 5.721
Authors: James G Jollis; Hussein R Al-Khalidi; Mayme L Roettig; Peter B Berger; Claire C Corbett; Shannon M Doerfler; Christopher B Fordyce; Timothy D Henry; Lori Hollowell; Zainab Magdon-Ismail; Ajar Kochar; James J McCarthy; Lisa Monk; Peter O'Brien; Thomas D Rea; Jay Shavadia; Jacqueline Tamis-Holland; B Hadley Wilson; Khaled M Ziada; Christopher B Granger Journal: Circulation Date: 2017-11-14 Impact factor: 29.690
Authors: Tracy Y Wang; Brahmajee K Nallamothu; Harlan M Krumholz; Shuang Li; Matthew T Roe; James G Jollis; Alice K Jacobs; David R Holmes; Eric D Peterson; Henry H Ting Journal: JAMA Date: 2011-06-22 Impact factor: 56.272
Authors: Robert W Yeh; Stephen Sidney; Malini Chandra; Michael Sorel; Joseph V Selby; Alan S Go Journal: N Engl J Med Date: 2010-06-10 Impact factor: 91.245
Authors: Elliott M Antman; Daniel T Anbe; Paul Wayne Armstrong; Eric R Bates; Lee A Green; Mary Hand; Judith S Hochman; Harlan M Krumholz; Frederick G Kushner; Gervasio A Lamas; Charles J Mullany; Joseph P Ornato; David L Pearle; Michael A Sloan; Sidney C Smith Journal: J Am Coll Cardiol Date: 2004-08-04 Impact factor: 24.094