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Do PCI Facility Openings and Closures Affect AMI Outcomes Differently in High- vs Average-Capacity Markets?

https://doi.org/10.1016/j.jcin.2023.02.010Get rights and content

Abstract

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 6.5% and 8.6% 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.

Section snippets

Data Sources

We used the 100% Medicare Provider and Analysis Review (MedPAR) and Medicare outpatient claims between 2005 and 2017 to identify PCI volume and the patient cohort. We used the American Hospital Association and the Healthcare Cost Report Information System to identify hospital characteristics, including their geographical coordinates. We used 2010 U.S. Census and 2011-2018 American Community Surveys to identify each ZIP Code community’s geographical coordinates and demographic information.

Results

Our study included 2,742,530 patients from 2006-2017. By study design, about one-quarter of patients lived in a high-capacity market, while the remaining three-quarters lived in an average-capacity market. Table 1 shows that communities that were classified as having high PCI capacity at baseline had a lower proportion of Black residents (9%) compared with communities with average PCI capacity at baseline (14%), as well as a lower proportion of low-income families (29% compared with 34% for

Discussion

In this analysis of PCI hospital openings and closures using national data from 2006 to 2017, PCI center openings within a 15-minute drive in average-capacity markets were associated with significant benefits in treatment access and outcomes for patients with AMI. These effects were not seen in high-capacity PCI markets. Specifically, in average-capacity markets, patients with AMI had a 6.5% and 8.6% relative increase in the likelihood of receiving revascularization on the day of admission and

Conclusions

PCI capacity has continued to grow in all communities, including communities with high baseline capacity, since 2006. Our findings lend credence to the notion that the opening of PCI services in a hospital has markedly different effects on communities depending on their baseline access to PCI services. Patients with AMI in average-capacity markets benefit substantially, whereas the effect observed for patients in high-capacity markets is small—or possibly even detrimental.

WHAT IS KNOWN? We know

Funding Support and Author Disclosures

This project was supported by the National Heart, Lung, and Blood Institute grants R01HL134182 and R01HL114822, and National Institute on Aging grant P30AG012810. Dr Krumholz has received expenses and/or personal fees from UnitedHealth, Element Science, Eyedentifeye, and F-Prime in the past three years; is a co-founder of Refactor Health and HugoHealth; and he is associated with contracts, through Yale New Haven Hospital, from the Centers for Medicare & Medicaid Services and through Yale

Acknowledgment

The authors thank Maddie Feldmeier for editorial assistance.

References (38)

  • R.Y. Hsia et al.

    Percutaneous coronary intervention in the united states: risk factors for untimely access

    Health Serv Res

    (2016)
  • Developer Guide - HERE Routing API. HERE Developer.

  • Y.C. Shen et al.

    Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality

    Health Aff (Millwood)

    (2015)
  • Y.C. Shen et al.

    Does decreased access to emergency departments affect patient outcomes? Analysis of acute myocardial infarction population 1996-2005

    Health Serv Res

    (2012)
  • AHRQ Quality Indicators: Inpatient Quality Indicators Technical Specifications

  • Y.-C. Shen et al.

    Association between emergency department closure and treatment, access, and health outcomes among patients with acute myocardial infarction

    Circulation

    (2016)
  • R.Y. Hsia et al.

    Evaluation of STEMI regionalization on access, treatment, and outcomes among adults living in nonminority and minority communities

    JAMA Netw Open

    (2020)
  • A. Chandra et al.

    Productivity spillovers in healthcare: evidence from the treatment of heart attacks

    J Polit Econ

    (2007)
  • A.V. Mohan et al.

    Changes in geographic variation in the use of percutaneous coronary intervention for stable ischemic heart disease after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial

    Circ Cardiovasc Qual Outcomes

    (2014)
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