Primary Stroke Center Hospitalization for Elderly Patients With Stroke: Implications for Case Fatality and Travel Times.

IMPORTANCE: Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care. OBJECTIVES: To examine the association of case fatality with receiving care in PSCs vs other hospitals for patients with stroke and to identify whether prolonged travel time offsets the effect of PSCs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. We used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims. EXPOSURES: Admission to a PSC. MAIN OUTCOMES AND MEASURES: Seven-day and 30-day postadmission case-fatality rates. RESULTS: Among 865 184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. We found that admission to PSCs was associated with 1.8% (95% CI, -2.1% to -1.4%) lower 7-day and 1.8% (95% CI, -2.3% to -1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling less than 90 minutes, but traveling at least 90 minutes offset any benefit of PSC care. CONCLUSIONS AND RELEVANCE: Hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSC admission.

Advanced Practice Registered Nurse supply in a small state: trends to inform policy.

This study is a contribution to the small existing pool of state level research on Advanced Practice Registered Nurse (APRN) workforce supply. Data from four biennial surveys of Vermont APRNs from 2003, 2005, 2007, and 2009 (n = 1,538) were analyzed to produce descriptive statistics of one small state's APRN demographic, educational, employment, job satisfaction, intention to leave, and practice-setting characteristics. Survey results were then used to identify patterns or trends that existed in the data. There was a marked shift in the employment settings and a decrease time worked as an APRN, despite an aging APRN workforce. There was an increase in the aggregate education level of APRNs; however, the percentage educated at the doctoral level remained flat at 2%. Overall, APRNs were a satisfied segment of the health workforce; however, those intending to leave for dissatisfaction voiced more concern about job stress and less concern about salary and benefits over time. Implications for workforce planning and public policy are discussed.

Geographic access to family planning facilities and the risk of unintended and teenage pregnancy.

OBJECTIVES: This study tested the hypotheses that greater geographic access to family planning facilities is associated with lower rates of unintended and teenage pregnancies. METHODS: State Pregnancy Risk Assessment Monitoring System (PRAMS) and natality files in four states were used to locate unintended and teenage births, respectively. Geographic availability was measured by cohort travel time to the nearest family planning facility, the presence of a family planning facility in a ZIP area, and the supply of primary care physicians and obstetric-gynecologists. RESULTS: 83% of the PRAMS cohort and 80% of teenagers lived within 15 min or less of a facility and virtually none lived more than 30 min. Adjusted odds ratios did not demonstrate a statistically significant trend to a higher risk of unintended pregnancies with longer travel time. Similarly there was no association with unintended pregnancy and the presence of a family planning facility within the ZIP area of maternal residence, or with the supply of physicians capable of providing family planning services. Both crude and adjusted relative rates of teenage pregnancies were significantly lower with further distance from family planning sites and with the absence of a facility in the ZIP area of residence. In adjusted models, the supply of obstetricians-gynecologists and primary care physicians was not significantly associated with decreased teen pregnancies. CONCLUSIONS: This study found no relationship between greater geographic availability of family planning facilities and a risk of unintended pregnancies. Greater geographic availability of family planning services was associated with a higher risk of teenage pregnancy, although these results may be confounded by facilities locating in areas with greater family planning needs.

Regionalization of high-risk surgery and implications for patient travel times.

CONTEXT: Given the strong volume-outcome relationships observed with many surgical procedures, restricting some procedures to hospitals exceeding a minimum volume standard is advocated. However, such regionalization policies might cause unreasonable travel burdens for surgical patients. OBJECTIVE: To estimate how minimum volume standards for esophagectomy and pancreatic resection would affect how long patients must travel for these procedures. DESIGN, SETTING, AND PATIENTS: Simulated trial based on Medicare claims and US road network data. All US hospitals in the 48 continental states were in the study if their surgical procedures included esophagectomy and pancreatic resection. Data from Medicare patients (N = 15,796) undergoing these 2 procedures for cancer between 1994 and 1999 were used. MAIN OUTCOME MEASURE: Additional travel time for patients required to change to higher-volume centers as a result of alternative hospital volume standards (procedures per year). RESULTS: With low-volume standards (1/year for pancreatectomy; 2/year for esophagectomy), approximately 15% of patients would change to higher-volume centers, with negligible effect on their travel times. Most patients would need to travel less than 30 additional minutes (74% pancreatectomy; 76% esophagectomy). Many patients already lived closer to a higher-volume hospital (25% pancreatectomy; 26% esophagectomy). Conversely, with very high-volume standards (>16/year for pancreatectomy; >19/year for esophagectomy), approximately 80% of patients would change to higher-volume centers. More than 50% of these patients would increase their travel time by more than 60 minutes. Travel times would increase most for patients living in rural areas. CONCLUSIONS: Many patients travel past a higher-volume center to undergo surgery at a low-volume hospital. If not set too high, hospital volume standards could be implemented for selected operations without imposing unreasonable travel burdens on patients.

Primary care service areas: a new tool for the evaluation of primary care services.

OBJECTIVE: To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians. DATA SOURCE/STUDY SETTING: The 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996). STUDY DESIGN: A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims. DATA COLLECTION/EXTRACTION METHODS: Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes. PRINCIPAL FINDINGS: The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical. CONCLUSIONS: Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.