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BACKGROUND AND OBJECTIVES: Mechanical thrombectomy (MT) improves outcomes for acute ischemic stroke (AIS) due to large vessel occlusion, but is time sensitive and requires specialized infrastructure. Professional organizations and certification bodies have promulgated minimum procedural volume standards for centers and for individual proceduralists but it is unclear whether enforcing these requirements would decrease geographic access to MT. Therefore, we sought to evaluate the potential impact of applying a minimum procedural volume threshold on geographic access to MT. METHODS: We identified all hospital discharges for stroke where an MT procedure was performed at any nonfederal hospital in Florida in 2019 using statewide hospital discharge data. We then generated geographic service area maps based on prespecified ground transport distances for the subset of hospitals that performed at least 1 MT and for those that performed at least 15 MTs that year, the minimum volume threshold required for thrombectomy capable and comprehensive stroke centers by the Joint Commission. Then, using zip code centroids and patient-level discharge hospital data, we computed the proportion of patients with AIS who lived within each of the generated service areas. RESULTS: A total of 105 of 297 hospitals performed MT; of those, 51 (17%) were low-volume centers (1-14 MTs/year) and 54 (18%) were high-volume centers (≥15 MTs/year). High-volume centers accounted for nearly 95% of all MTs performed in the state. Most patients hospitalized with AIS (87%) lived within 20 miles (or an estimated as a 1-hour driving time) of a hospital that performed at least 1 MT, and all (100%) lived within 115 miles (or estimated as 3-hour driving time). Setting a minimum MT volume threshold of 15 would decrease the proportion of stroke patients living within 1-hour driving time of an MT center from 87% to 77%. DISCUSSION: In 2019, most Florida stroke patients lived within a 1-hour ground transport time to a center that performed at least 1 MT and all lived within 3-hour driving time of an MT center, irrespective of whether a minimum procedural volume threshold of 15 cases per year was applied or not.

OBJECTIVE: To use more precise measures of which hospitals are electronically connected to determine whether health information exchange (HIE) is associated with lower emergency department (ED)-related utilization. MATERIALS AND METHODS: We combined 2018 Medicare fee-for-service claims to identify beneficiaries with 2 ED encounters within 30 days, and Definitive Healthcare and AHA IT Supplement data to identify hospital participation in HIE networks (HIOs and EHR vendor networks). We determined whether the 2 encounters for the same beneficiary occurred at: the same organization, different organizations connected by HIE, or different organizations not connected by HIE. Outcomes were: (1) whether any repeat imaging occurred during the second ED visit; (2) for beneficiaries with a treat-and-release ED visit followed by a second ED visit, whether they were admitted to the hospital after the second visit; (3) for beneficiaries discharged from the hospital followed by an ED visit, whether they were admitted to the hospital. RESULTS: In adjusted mixed effects models, for all outcomes, beneficiaries returning to the same organization had significantly lower utilization compared to those going to different organizations. Comparing only those going to different organizations, HIE was not associated with lower levels of repeat imaging. HIE was associated with lower likelihood of hospital admission following a treat-and-release ED visit (1.83 percentage points [-3.44 to -0.21]) but higher likelihood of admission following hospital discharge (2.78 percentage points [0.48-5.08]). DISCUSSION: Lower utilization for beneficiaries returning to the same organization could reflect better access to information or other factors such as aligned incentives. CONCLUSION: HIE is not consistently associated with utilization outcomes reflecting more coordinated care in the ED setting.

BACKGROUND: Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer. METHODS: This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center. RESULTS: Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer. CONCLUSIONS: Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.

Background Racially and ethnically minoritized groups, people with lower income, and rural communities have worse access to percutaneous coronary intervention (PCI) than their counterparts, but PCI hospitals have preferentially opened in wealthier areas. Our study analyzed disparities in PCI access, treatment, and outcomes for patients with acute myocardial infarction based on the census-derived Area Deprivation Index. Methods and Results We obtained patient-level data on 629 419 patients with acute myocardial infarction in California between January 1, 2006 and December 31, 2020. We linked patient data with population characteristics and geographic coordinates, and categorized communities into 5 groups based on the share of the population in low or high Area Deprivation Index neighborhoods to identify differences in PCI access, treatment, and outcomes based on community status. Risk-adjusted models showed that patients in the most advantaged communities had 20% and 15% greater likelihoods of receiving same-day PCI and PCI during the hospitalization, respectively, compared with patients in the most disadvantaged communities. Patients in the most advantaged communities also had 19% and 16% lower 30-day and 1-year mortality rates, respectively, compared with the most disadvantaged, and a 15% lower 30-day readmission rate. No statistically significant differences in admission to a PCI hospital were observed between communities. Conclusions Patients in disadvantaged communities had lower chances of receiving timely PCI and a greater risk of mortality and readmission compared with those in more advantaged communities. These findings suggest a need for targeted interventions to influence where cardiac services exist and who has access to them.

BACKGROUND: Emergency department (ED) utilization is a significant concern in many countries, but few population-based studies have compared ED use. Our objective was to compare ED utilization in New York (United States), Ontario (Canada), and New Zealand (NZ). METHODS: A retrospective cross-sectional analysis of all ED visits between January 1, 2016, and September 30, 2017, for adults ≥18 years using data from the State Emergency Department and Inpatient Databases (New York), the National Ambulatory Care Reporting System and Discharge Abstract Data (Ontario), and the National Non-Admitted Patient Collection and the National Minimum Data Set (New Zealand). Outcomes included age- and sex-standardized per-capita ED utilization (overall and stratified by neighborhood income), ED disposition, and ED revisit and hospitalization within 30 days of ED discharge. RESULTS: There were 10,998,371 ED visits in New York, 8,754,751 in Ontario, and 1,547,801 in New Zealand. Patients were older in Ontario (mean age 51.1 years) compared to New Zealand (50.3) and New York (48.7). Annual sex- and age-standardized per-capita ED utilization was higher in Ontario than New York or New Zealand (443.2 vs. 404.0 or 248.4 visits per 1000 population/year, respectively). In all countries, ED utilization was highest for residents of the lowest income quintile neighborhoods. The proportion of ED visits resulting in hospitalization was higher in New Zealand (34.5%) compared to New York (20.8%) and Ontario (12.8%). Thirty-day ED revisits were higher in Ontario (27.0%) than New Zealand (18.6%) or New York (21.4%). CONCLUSIONS: Patterns of ED utilization differed widely across three high-income countries. These differences highlight the varying approaches that our countries take with respect to urgent visits, suggest opportunities for shared learning through international comparisons, and raise important questions about optimal approaches for all countries.

ImportanceThe health care system has undergone major changes in the past decade, and emergency department (ED) crowding has worsened over time; however, the most recent patterns in ED capacity and use in California have yet to be studied.ObjectiveTo analyze patterns in ED capacity and utilization in California hospitals from 2011 to 2021.Design, setting, and participantsThis retrospective cohort study used data from the California Department of Health Care Access and Information and the US Census Bureau to analyze ED facility characteristics from more than 400 general acute care hospitals with more than 320 EDs in California as well as patients who presented to those EDs between January 1, 2011, and December 31, 2021.Main outcomes and measuresLinear patterns (measured by percentage change) in total annual ED capacity (volume of hospital beds, EDs, ED treatment stations, and trauma centers) and ED use (ED visits by disposition and acuity) were assessed as primary outcomes. Patterns in ambulance diversion hours and the number of patients who left the ED without being seen were also examined as secondary outcomes. Visit acuity was categorized into 5 levels by increasing severity (minor, low to moderate, moderate, severe without threat, and severe with threat) based on California Department of Health Care Access and Information descriptions corresponding to Current Procedural Terminology codes.ResultsIn the prepandemic period (2011-2019), the total population of California increased from 37 638 369 to 39 512 223 (5.0%; 95% CI, 4.1%-5.8%), then decreased to 39 237 836 in 2021 (0.7%; 95% CI, -3.9% to 2.5%). Over the entire study period (2011-2021), the total California population increased by 4.2% (95% CI, 3.3%-5.2%). From 2011 to 2019, the annual number of ED visits increased from 12 054 885 to 14 876 653 (23.4%; 95% CI, 20.0%-26.8%) before decreasing to 12 944 692 in 2021 (-13.0%; 95% CI, -33.1% to 7.1%); from 2011 to 2021, total ED visits increased by 7.4% (95% CI, 5.6%-9.1%). From 2011 to 2021, the total number of EDs decreased from 339 to 326 (-3.8%; 95% CI, -4.4% to -3.2%) and the total number of hospital beds decreased from 75 940 to 74 052 (-2.5%; 95% CI, -3.3% to -1.6%), while the number of ED treatment stations in these fewer EDs increased from 7159 to 8667 (21.1%; 95% CI, 19.7%-22.4%). The number of visits rated as severe with threat also increased, from 2 011 637 in 2011 to 3 375 539 in 2021 (67.8%; 95% CI, 59.7%-75.9%), while visits rated as minor decreased from 913 712 to 336 071 (-63.2%; 95% CI, -75.2% to -51.2%) over the same period.Conclusions and relevanceIn this cohort study, multiple measures of ED capacity did not proportionally increase with the increasing demand for services; however, the COVID-19 pandemic appears to have substantially affected some of these patterns. These findings may be helpful to policy makers and health care stakeholders when planning resource allocation of limited health care resources.

BACKGROUND: Disparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes. OBJECTIVES: The authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets. METHODS: In this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models. RESULTS: From 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 5.5% and 7.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets. CONCLUSIONS: After openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.

Using 11 years of the U.S. Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System survey data set for 2011 to 2021, we track the evolution of depression risk for U.S. states and territories before and during the COVID-19 pandemic. We use these data in conjunction with unemployment and COVID case data by state and by year to describe changes in the prevalence of self-reported diagnosis with a depressive disorder over time and especially after the onset of COVID in 2020 and 2021. We further investigate heterogeneous associations of depression risk by demographic characteristics. Regression analyses of these associations adjust for state-specific and period-specific factors using state and year-fixed effects. First, we find that depression risk had been increasing in the US in years preceding the pandemic. Second, we find no significant average changes in depression risk at the onset of COVID in 2020 relative to previous trends, but estimate a 3% increase in average depression risk in 2021. Importantly, we find meaningful variation in terms of changes in depression risk during the pandemic across demographic subgroups.

IntroductionOver the past two decades, percutaneous coronary intervention (PCI) capacity has increased while coronary artery disease has decreased, potentially lowering per-hospital PCI volumes, which is associated with less favorable patient outcomes. Trends in the likelihood of receiving PCI in a low-volume center have not been well-documented, and it is unknown whether certain socioeconomic factors are associated with a greater risk of PCI in a low-volume facility. Our study aims to determine the likelihood of being treated in a low-volume PCI center over time and if this likelihood differs by sociodemographic factors.MethodsWe conducted a retrospective cohort study of 374,066 hospitalized patients in California receiving PCI from January 1, 2010, to December 31, 2018. Our primary outcome was the likelihood of PCI discharges at a low-volume hospital (

Introduction: Falls are the leading cause of traumatic injury among elderly adults in the United States, which represents a significant source of morbidity and leads to exorbitant healthcare costs. The purpose of this study was to characterize elderly fall patients and identify risk factors associated with seven-day emergency department (ED) revisits. Methods: This was a multicenter, retrospective, longitudinal cohort study using non-public data from 321 licensed, nonfederal, general, and acute care hospitals in California obtained from the Department of Healthcare Access and Information from January 1–December 31, 2017. Included were patients 65 and older who had a fall-related ED visit identified by International Classification of Diseases codes W00x to W19x. Primary outcome was a return visit to the ED within a seven-day window following the index encounter. Demographics collected included age, gender, ethnicity/race, patient payer status, Charlson Comorbidity Index (CCI), psychiatric diagnoses, and alcohol/substance use disorder diagnoses. We performed multivariate logistic regression to identify characteristics associated with seven-day ED revisit. Results: We identified a total of 2,758,295 ED visits during the study period with 347,233 (12.6%) visits corresponding to fall-related injuries. After applying exclusion criteria, 242,572 index ED visits were identified, representing 206,612 patients. Of these, 24,114 (11.7%) patients returned to an ED within seven days (revisit). Within this revisit population, 6,161 (22.6%) presented to a facility that was distinct from their index visit, and 4,970 (18.2%) were ultimately discharged with the same primary diagnosis as their index visit. Characteristics with the largest independent associations with a seven-day ED revisit were presence of a psychiatric diagnosis (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.69 to 1.80), presence of an alcohol or substance use disorder (OR 1.70; 95% CI 1.64 to 1.78), and CCI ≥ 3 (OR 2.79; 95% CI 2.68 to 2.90). Conclusion: In this study we identified 24,114 elderly fall patients who experienced a seven-day ED revisit. Patients with multiple comorbidities, a substance use disorder, or a psychiatric diagnosis exhibited increased odds of experiencing a return visit to the ED within seven days of a fall-related index visit. These findings will help target at-risk elderly fall patients who may benefit from preventative multidisciplinary intervention during index ED visits to reduce ED revisits.

California emergency departments (EDs) treated about 143,000 people experiencing homelessness in 2019, according to hospital discharge records. Almost half of homeless patients visited the ED four or more times in the year.Medi-Cal covered 70 percent of ED visits by homeless patients, underscoring the importance of the CalAIM program, which provides added Medi-Cal benefits, such as housing supports and case management.Linking discharge data with homeless assistance program data can offer insights into how people engage with EDs and homeless services across the state, and throughout the year, as well as help evaluate programs and public investments.This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grants MRP-19-600774 and M21PR3278

Background: It is unknown how changes in the percutaneous coronary intervention (PCI) "built environment" have impacted PCI volumes at the community, hospital, and patient levels. This study sought to determine how PCI hospital openings and closures effect community‐ and hospital‐level PCI volumes as well as the likelihood of receiving PCI at a low‐volume hospital. Methods: We conducted a retrospective cohort study of 3,966,025 Medicare Fee‐For‐Service patients in 37,451 zip codes and 2564 U.S. hospitals who underwent PCI from 2006 to 2017. We conducted community‐, hospital‐, and patient‐level analyses using ordinary least squares regressions with fixed effects to determine changes in PCI volumes after PCI hospital openings or closures. Results: Between 2006 and 2017, a total of 17% and 7% of patients lived in communities that experienced PCI hospital openings and closures, respectively. Openings were associated with a 10% increase in community PCI volume, a 2% increase in the share of elective PCI, and a doubling in the likelihood of receiving PCI at a low‐volume hospital. In communities with low baseline PCI capacity, openings were associated with a 12% increase in community PCI volume, and in high‐capacity communities, an 8% increase. PCI closures were associated with a 9% decrease in community PCI volume in high‐capacity communities but no measurable change in low‐capacity communities. Conclusions: PCI service expansion is associated with increased PCI at low‐volume hospitals and a greater number of elective procedures. Increased governmental oversight may be necessary to ensure that openings and closures of these specialized services yield the desired benefits. [ABSTRACT FROM AUTHOR]

Background: Timely reperfusion is necessary to reduce morbidity and mortality in patients with ST‐elevation myocardial infarction (STEMI). Initial care by facilities with percutaneous coronary intervention (PCI) capabilities reduces time to reperfusion. We sought to examine whether insurance status was associated with initial care at emergency departments (EDs) with PCI capabilities among adult patients with STEMI. Methods: We conducted a retrospective cross‐sectional study using Department of Healthcare Access and Information, a nonpublic statewide database reporting ED visits and hospitalizations in California. We included adults initially arriving at EDs with STEMI by diagnostic code (International Classification of Diseases Ninth Revision or 10th Revision) from 2011 to 2019. Multivariable logistic regression modeling included initial care by PCI capable facility as the primary outcome and insurance status (none vs. any) as the primary exposure. Covariates included patient, facility, and temporal factors and we conducted multiple robustness checks. Results: We analyzed 135,358 eligible visits with STEMI included. In our multivariable model, the odds of uninsured patients being initially treated at a PCI‐capable facility were significantly lower than those of insured patients (adjusted odds ratio 0.62, 95% CI 0.54–0.72, p < 0.001) and was unchanged in sensitivity analyses. Conclusions: Uninsured patients with STEMI had significantly lower odds of first receiving care at facilities with PCI capabilities. Our results suggest potential disparities in accessing high‐quality and time‐sensitive treatment for uninsured patients with STEMI. [ABSTRACT FROM AUTHOR]

Objective To use more precise measures of which hospitals are electronically connected to determine whether health information exchange (HIE) is associated with lower emergency department (ED)-related utilization. Materials and Methods We combined 2018 Medicare fee-for-service claims to identify beneficiaries with 2 ED encounters within 30 days, and Definitive Healthcare and AHA IT Supplement data to identify hospital participation in HIE networks (HIOs and EHR vendor networks). We determined whether the 2 encounters for the same beneficiary occurred at: the same organization, different organizations connected by HIE, or different organizations not connected by HIE. Outcomes were: (1) whether any repeat imaging occurred during the second ED visit; (2) for beneficiaries with a treat-and-release ED visit followed by a second ED visit, whether they were admitted to the hospital after the second visit; (3) for beneficiaries discharged from the hospital followed by an ED visit, whether they were admitted to the hospital. Results In adjusted mixed effects models, for all outcomes, beneficiaries returning to the same organization had significantly lower utilization compared to those going to different organizations. Comparing only those going to different organizations, HIE was not associated with lower levels of repeat imaging. HIE was associated with lower likelihood of hospital admission following a treat-and-release ED visit (1.83 percentage points [−3.44 to −0.21]) but higher likelihood of admission following hospital discharge (2.78 percentage points [0.48-5.08]). Discussion Lower utilization for beneficiaries returning to the same organization could reflect better access to information or other factors such as aligned incentives. Conclusion HIE is not consistently associated with utilization outcomes reflecting more coordinated care in the ED setting. [ABSTRACT FROM AUTHOR]