Heterogeneity of State Stroke Center Certification and Designation Processes.

BACKGROUND: Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. METHODS: In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. RESULTS: Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). CONCLUSIONS: Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.

Trends in Inequities in the Treatment of and Outcomes for Women and Minorities with Myocardial Infarction.

STUDY OBJECTIVE: To test whether the differences across sex and race in the treatment of and outcomes for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) have changed over a recent decade. METHODS: We conducted a retrospective analysis of patients with a diagnosis of STEMI or NSTEMI in California from 2005 to 2015 using the Office of State Health Planning and Development dataset. Using multivariable linear regression with county-fixed effects, we measured the baseline and change over time in the proportions of patients with STEMI or NSTEMI who underwent appropriately-timed coronary angiography (day of admission and within 3 days of admission, respectively) and survived at 1 year according to sex and race (Asian, Black, Hispanic, and White) and adjusting for comorbidities, payor, and hospital characteristics. RESULTS: We analyzed 159,068 STEMI and 294,068 NSTEMI presentations. In 2005, 50.0% of 12,329 men and 35.7% of 6,939 women with STEMI and 45.0% of 14,379 men and 33.1% of 10,674 women with NSTEMI underwent timely angiography. In 2015, 76.7% of 6,257 men and 66.8% of 2,808 women with STEMI underwent timely angiography and 56.3% of 13,889 men and 45.9% of 9,334 women with NSTEMI underwent timely angiography. In 2005, 1-year survival was 82.3% for men and 69.6% for women after STEMI; in 2013, 1-year survival was 88.1% for men and 79.1% for women. In the multivariable model, the baseline difference was 1.1 percentage points (95% confidence interval [CI] 0.2 to 1.9), and survival increased for women compared with men by 0.3 percentage points per year (95% CI 0.2 to 0.5). In 2005, 46.0% (5,878) of 12,789 White patients and 31.2% (330) of 1,057 Black patients with STEMI underwent timely angiography; in 2015 75.2% of 3,928 White patients and 69.2% of 522 Black patients underwent timely angiography for STEMI. In the multivariable model, this difference was 6.4 percentage points at baseline (95% CI 4.5 to 8.3), and the probability of undergoing timely angiography for Black patients increased by 0.3 percentage points per year (95% CI -0.1 to 0.6). CONCLUSION: Despite overall improvements in the treatment of and outcomes for STEMI and NSTEMI, disparities persist in the treatment of and outcomes for both the conditions, particularly for women.

Association of STEMI regionalization of care with de facto NSTEMI regionalization.

The regionalization of care for ST elevation myocardial infarction (STEMI) may unintentionally concentrate patients with non-ST elevation myocardial infarction (NSTEMI) into percutaneous coronary intervention (PCI) capable hospitals. This could lead to benefits such as increased access to PCI-capable hospitals, but could cause harms such as crowding in some hospitals with decreased patient volume and revenue in others. We set out to assess whether STEMI regionalization programs concentrated patients with NSTEMI at STEMI-receiving hospitals.

Comparison of Long-run Trends in 30-day Readmission by Degrees of Medicare Payment Cuts.

BACKGROUND AND OBJECTIVE: The Affordable Care Act enacted significant Medicare payment reductions to providers, yet long-term effects of such major reductions on patient outcomes remain uncertain. Using the 1997 Balanced Budget Act (BBA) as an experiment, we compare long-run trends in 30-day readmission across hospitals with different amount of payment cuts. RESEARCH DESIGN, SUBJECTS, AND MEASURES: Using 100% Medicare claims between 1995 and 2011 and instrumental variable hospital fixed-effects regression models, we compared changes in 30-day readmission trends for 5 leading Medicare conditions between urban hospitals facing small, moderate, and large BBA payment reductions across 4 periods [1995-1997 (pre-BBA period), 1998-2000, 2001-2005, 2006-2001]. Patient sample includes Medicare patients who were admitted to general, acute, urban, short-stay hospitals in the United States 1995-2011. Sample size ranges from 1.4 million patients for acute myocardial infarction to 3 million for pneumonia. RESULTS: We found that 30-day readmission trends diverged post-BBA (2001-2005) between hospitals facing small and large payment cuts, where large-cut hospitals experience slower improvement in readmission rates relative to small-cut hospitals. The gap between small-cut and large-cut hospitals readmission trend was 6% for acute myocardial infarction, 4% for congestive heart failure and pneumonia (all P<0.01) in the 2001-2005 period. The gaps between hospitals were eliminated by the 2006-2011 period as the effect of BBA naturally dissipated over time. CONCLUSIONS: Although payment-cut differences are associated with widening gaps in readmission rates across hospitals, the negative association appears to dissipate in the long run.

Decomposition of the drivers of the U.S. hospital spending growth, 2001-2009.

BACKGROUND: United States health care spending rose rapidly in the 2000s, after a period of temporary slowdown in the 1990s. However, the description of the overall trend and the understanding of the underlying drivers of this trend are very limited. This study investigates how well historical hospital cost/revenue drivers explain the recent hospital spending trend in the 2000s, and how important each of these drivers is. METHODS: We used aggregated time series data to describe the trend in total hospital spending, price, and quantity between 2001 and 2009. We used the Oaxaca-Blinder method to investigate the relative importance of major hospital cost/spending drivers (derived from the literature) in explaining the change in hospital spending patterns between 2001 and 2007. We assembled data from Medicare Cost Reports, American Hospital Association annual surveys, Prospective Payment System (PPS) Impact Files, Medicare Provider Analysis and Review (MedPAR) Medicare claims data, InterStudy reports, National Health Expenditure data, and Area Resource Files. RESULTS: Aggregated time series trends show that high hospital spending between 2001 and 2009 appears to be driven by higher payment per unit of hospital output, not by increased utilization. Results using the Oaxaca-Blinder regression decomposition method indicate that changes in historically important spending drivers explain a limited 30% of unit-payment growth, but a higher 60% of utilization growth. Hospital staffing and labor-related costs, casemix, and demographics are the most important drivers of higher hospital revenue, utilization, and unit-payment. Technology is associated with lower utilization, higher unit payment, and limited increases in total revenue. Market competition, primarily because of increased managed care concentration, moderates total revenue growth by driving lower unit payment. CONCLUSIONS: Much of the rapidly rising hospital spending growth in the 2000s in the United States is driven by factors not commonly known or well measured. Future studies need to explore new factors and dynamics that drive longer-term hospital spending growth in recent years, particularly through the channel of higher prices.

Structural Inequities In The Adoption Of Percutaneous Coronary Intervention Services By US Hospitals, 2000-20.

Percutaneous coronary intervention (PCI) is a procedure that opens blocked arteries and restores blood flow to the heart. Timely access to hospitals offering PCI services can be a matter of life or death for patients experiencing a heart attack; however, hospitals' adoption of PCI services may vary between communities, posing potential barriers to critical care. Our cohort study of US general acute hospitals during the period 2000-20 examined PCI service adoption across communities stratified by race, ethnicity, income, and rurality and further classified as segregated or integrated. Of 5,260 hospitals, 1,621 offered PCI services in 2020 or before, 630 added PCI services between 2001 and 2010, and 225 added PCI services between 2011 and 2020. Hospitals serving Black, racially segregated communities were 48 percent less likely to adopt PCI services compared with hospitals serving non-Black, racially segregated communities, and hospitals serving Hispanic, ethnically segregated communities were 41 percent less likely to do so than those serving non-Hispanic, ethnically segregated communities. Hospitals in high-income, economically integrated communities were 1.8 times more likely to adopt PCI services than those in high-income, economically segregated communities, and rural hospitals were less likely to do so than urban hospitals. Understanding where services are expanding in relation to community need may aid in successful policy interventions.

Provision of Stroke Care Services by Community Disadvantage Status in the US, 2009-2022.

Importance: Stroke center certification is granted to facilities that demonstrate distinct capabilities for treating patients with stroke. A thorough understanding of structural discrimination in the provision of stroke centers is critical for identifying and implementing effective interventions to improve health inequities for socioeconomically disadvantaged populations. Objective: To determine whether (1) hospitals in socioeconomically disadvantaged communities (defined using the Area Deprivation Index) are less likely to adopt any stroke certification and (2) adoption rates differ between entry-level (acute stroke-ready hospitals) and higher-level certifications (primary, thrombectomy capable, and comprehensive) by community disadvantage status. Design, Setting, and Participants: This cohort study used newly collected stroke center data merged with data from the American Hospital Association, Healthcare Cost Report Information datasets, and the US Census. All general acute hospitals in the continental US between January 1, 2009, and December 31, 2022, were included. Data analysis was conducted from July 2023 to May 2024. Main Outcomes and Measures: The primary outcome was the likelihood of hospitals adopting stroke care certification. Cox proportional hazard and competing risk models were used to estimate the likelihood of a hospital becoming stroke certified based on the socioeconomic disadvantage status of the community. Results: Among the 5055 hospitals studied from 2009 to 2022, 2415 (47.8%) never achieved stroke certification, 602 (11.9%) were certified as acute stroke-ready hospitals, and 2038 (40.3%) were certified as primary stroke centers or higher. When compared with mixed-advantage communities, adoption of any stroke certification was most likely to occur near the most advantaged communities (hazard ratio [HR], 1.24; 95% CI, 1.07-1.44) and least likely near the most disadvantaged communities (HR, 0.43; 95% CI, 0.34-0.55). Adoption of acute stroke-ready certification was most likely in mixed-advantage communities, while adoption of higher-level certification was more likely in the most advantaged communities (HR,1.41; 95% CI, 1.22-1.62) and less likely for the most disadvantaged communities (HR, 0.31; 95% CI, 0.21-0.45). After adjusting for population size and hospital capacity, compared with mixed-advantage communities, stroke certification adoption hazard was still 20% lower for relatively disadvantaged communities (adjusted HR, 0.80; 95% CI, 0.73-0.87) and 42% lower for the most disadvantaged communities (adjusted HR, 0.58; 95% CI, 0.45-0.74). Conclusions and Relevance: In this cohort study examining hospital adoption of stroke services, when compared with mixed-advantage communities, hospitals located in the most disadvantaged communities had a 42% lower hazard of adopting any stroke certification and relatively disadvantaged communities had a 20% lower hazard of adopting any stroke certification. These findings suggest that there is a need to support hospitals in disadvantaged communities to obtain stroke certification as a way to reduce stroke disparities.

Core Mental Health Clinician Capacity and Use Rates in the US Military.

Importance: Active duty service members have higher mental health stress and cannot choose where to live. It is imperative to understand how geographic access may be associated with their ability to obtain mental health treatment and how the COVID-19 pandemic was associated with these patterns. Objective: To identify changes in the prevalence and intensity of mental health care use when service members experienced changes in core mental health clinician (defined to include psychiatrists, psychiatric nurse practitioners, clinical psychologists and social workers, and marriage and family therapists) capacity in their communities and whether patterns changed from before to after the onset of the COVID-19 pandemic. Design, Setting, and Participants: This retrospective cohort study of the active duty population between January 1, 2016, and December 31, 2022, was conducted using individual fixed-effects models to estimate changes in the probability of mental health care visits and visit volume when a person moved across communities with adequate core mental health clinician capacity (≥1 clinician/6000 beneficiaries), shortage areas (<1 clinician/6000 beneficiaries), and areas with 0 clinicians within a 30-minute drive time. All US active duty service members stationed in the continental US, Hawaii, and Alaska were included. Data were analyzed from January through July 2024. Main Outcomes and Measures: The first set of outcomes captured the probability of making at least 1 mental health care visit in a given quarter; the second set of outcomes captured the intensity of visits (ie, the number of visits log transformed). Results: This study included 33 039 840 quarterly observations representing 2 461 911 unique active duty service members from the Army, Navy, Marines, and Air Force (1 959 110 observations among Asian or Pacific Islander [5.9%], 5 309 276 observations among Black [16.1%], 5 287 168 observations among Hispanic [16.0%], and 18 739 827 observations among White [56.7%] individuals; 27 473 563 observations among males [83.2%]; mean [SD] age, 28.20 [7.78] years). When an active duty service member moved from a community with adequate capacity at military treatment facilities to one with 0 clinicians within a 30-minute drive, the probability of a mental health visit to any clinician decreased by 1.13 percentage points (95% CI, -1.21 to -1.05 percentage points; equivalent to a 11.6% relative decrease) and the intensity of total visits was reduced by 7.7% (95% CI, -9.0% to -6.5%). The gap increased from before to after the onset of the COVID-19 pandemic, from 8.5% (equivalent to -0.82 percentage points [95% CI, -0.92 to -0.73 percentage points]) to 16.2% (equivalent to -1.58 percentage points [95% CI, -1.70 to -1.46 percentage points]) in the probability of visiting any clinician type for mental health. Conclusions and Relevance: In this study, active duty personnel assigned to locations without core military mental health clinicians within a 30-minute drive time were less likely to obtain mental health care and had fewer mental health care visits than those in communities with adequate military mental health capacity even if there was adequate coverage from the civilian sector. The care disparity increased after the onset of the COVID-19 pandemic.

Is more better? A multilevel analysis of percutaneous coronary intervention hospital openings and closures on patient volumes.

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.

Geographic Access to High-Volume Mechanical Thrombectomy Centers in Florida, 2019.

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.

Reductions in Medicare payments and patient outcomes: an analysis of 5 leading Medicare conditions.

BACKGROUND: The Affordable Care Act enacted significant Medicare payment reductions to providers, yet the effects of such major reductions on patients remain unclear. We used the Balanced Budget Act (BBA) of 1997 as a natural experiment to study the long-term consequence of major payment reductions on patient outcomes. OBJECTIVES: To analyze whether mortality trends diverge over the years between hospitals facing different levels of payment cuts because of the BBA for 5 leading conditions: acute myocardial infarction, congestive heart failure, stroke, pneumonia, and hip fracture. RESEARCH DESIGN: Using 100% Medicare claims between 1995 and 2005, hospital database, and published reports on BBA policy components, we compared changes in outcomes between hospitals facing small and large BBA payment reductions across 3 periods (pre-BBA, initial-BBA, and post-BBA) using instrumental variable hospital fixed-effects regression models. SETTING: All general, acute, nonrural, short-stay hospitals in the United States 1995-2005. MAIN OUTCOME MEASURES: Hospital risk-adjusted mortality rates (7, 30, 90 d, and 1 y). RESULTS: Mortality trends between hospitals in small and large payment-cut categories were similar between pre-BBA and initial-BBA periods, but diverged in the post-BBA period. Relative to the small-cut hospitals, hospitals in the large-cut category experienced smaller decline in 1-year mortality rates in the post-BBA period compared with their pre-BBA trends by 0.8-1.4 percentage points, depending on the condition (P<0.05 for all conditions, except for hip fracture). CONCLUSION: We found consistent evidence across multiple conditions that reductions in Medicare payments are associated with slower improvement in mortality outcomes.

Can major systematic reviews influence practice patterns? A case study of episiotomy trends.

PURPOSE: Episiotomy is one of the most commonly performed procedures among women of childbearing age in the United States. In 2005, a major systematic review conducted by Hartmann and colleagues recommended against routine use of episiotomy and was widely covered in the media. We assessed the impact of the Hartman et al. study on episiotomy trend. METHODS: Based on 100% hospital discharge data from eight states in 2003-2008, we used interrupted time series regression models to estimate the impact of the Hartman et al. review on episiotomy rates. We used mixed-effects regression models to assess whether interhospital variation was reduced over time. RESULTS: After controlling for underlying trend, episiotomy rates dropped by 1.4 percentage points after Hartman et al. publication (p < 0.01 for spontaneous delivery; p < 0.1 for operative delivery). The publication has smaller effect on government hospitals as compared to private hospitals. Mixed effects models estimated negative correlation between cross-time and cross-hospital variations in episiotomy rates, indicating reduced cross-hospital variation over time. CONCLUSIONS: Our results suggested that there has been a gradual decline in episiotomy rates over the period 2003-2008, and that synthesis of evidence showing harms from routine episiotomy had limited impact on practice patterns in the case of episiotomy. The experience of episiotomy illustrates the challenge of using comparative effectiveness and evidenced-based medicine to reduce use of unnecessary procedures.

Propensity of US Military Personnel to Seek Mental Health Care When Community Psychiatric Capacity Changes.

Importance: Understanding how the active duty military population's mental health care use is associated with local military and civilian psychiatrist capacity is critical in designing the optimal allocation of mental health resources from both sectors to improve the mental health of military personnel. Objective: To evaluate whether the probability of mental health care visits by military personnel changes when psychiatrist capacity changes in their communities, when capacity is measured separately for military treatment facilities and civilian sectors. Design, Setting, and Participants: This cohort study of active duty US military service members between January 1, 2016, and September 30, 2020, combines data from the Defense Health Agency, the National Plan and Provider Enumeration System, and the US Census. Data were collected and analyzed from June 2022 to July 2023. Main Outcomes and Measures: The main outcome was the probability of making at least 1 mental health care visit in a given quarter at military treatment facilities and in civilian settings. Linear probability models with 2-dimensional fixed effects at individual and community levels were implemented to estimate changes in individual outcomes when community psychiatrist capacity changed. Results: This study includes 1 958 421 US service members (83% men; mean [SD] age at baseline, 28.4 [8.0] years). Thirteen percent of service members did not have military treatment facility psychiatrists available within a 30-minute driving time, and 66% lived in communities with a psychiatrist shortage (<1 psychiatrist per 20 000 relevant population), while 9% lived in communities with high (>3 psychiatrists per 20 000 relevant population) military treatment facility psychiatrist capacity. Five percent of service members lived in communities with no civilian psychiatrists within a 30-minute driving time, while 66% lived in communities with high civilian psychiatrist capacity. The mean quarterly mental health care visit rates to military treatment facilities and civilian settings were 7% and 2%, respectively. The probability of a mental health care visit to a military treatment facility increased by 0.95 percentage points (95% CI, 0.79-1.10 percentage points; equivalent to 14%) when the individual experienced a change in military treatment facility capacity from no psychiatrist to high capacity. The probability of a mental health care visit to a civilian setting increased by 0.57 percentage points (95% CI, 0.38-0.76 percentage points; equivalent to 32%) when civilian capacity changed from no psychiatrist to high capacity. The magnitude of responses to military treatment facility capacity changes remained similar in communities that already had high civilian capacity. Conclusions and Relevance: This cohort study of the US military population suggests that active duty military personnel rely largely on military treatment facilities for their mental health care and that there are meaningful responses to military treatment facility psychiatrist capacity changes even in communities with high civilian psychiatric capacity. Realigning military treatment facility psychiatrists across communities with shortages and high-capacity military treatment facilities, as well as addressing nongeographical barriers in the civilian sector, remain critical to achieve the optimal balance between military and civilian care provision.

Spatial Analysis of Access to Psychiatrists for US Military Personnel and Their Families.

Importance: Military service members and their families have greater mental health care needs compared with their civilian counterparts. Some communities have inadequate access to psychiatrists for this population. Objectives: To identify geographic variations in the availability of military and civilian psychiatrists within a 30-minute driving time of TRICARE (the US military's health care program) beneficiaries' communities and compare the likelihood of living in areas with inadequate access to psychiatrists for historically underserved and other communities. Design, Setting, and Participants: This retrospective cohort study of all zip code communities in the continental US, Hawaii, and Alaska with at least one TRICARE beneficiary between January 1, 2016, and September 30, 2020, combines data from the Defense Health Agency, the National Plan and Provider Enumeration System, and the US Census to estimate a logistic regression to compare differences between communities with and without a psychiatrist shortage. Data were analyzed from September 2021 to November 2022. Main Outcomes and Measures: A community's likelihood of having a shortage of military and civilian psychiatrists within a 30-minute driving time and a community's likelihood of having no psychiatrists. Odds ratios were calculated to estimate likelihood of the outcomes. Results: This study includes 39 487 unique communities where 13% of the population is Black and 14% of the population is Hispanic. During the study period, 35% of TRICARE beneficiaries lived in communities with a shortage of both military and civilian psychiatrists, and 6% lived in communities with no access to military or civilian psychiatrists. Low-income communities with high income inequality were 1.64 (95% CI, 1.30-2.07) times more likely to have inadequate access to psychiatrists and 2.59 (95% CI, 1.82-3.69) times more likely to have no access to psychiatrists, compared with reference communities (average income without high income inequality); low-income communities without high income inequality were 1.37 (95% CI, 1.05-1.78) times more likely to have inadequate access to psychiatrists and 1.93 (95% CI, 1.28-2.89) times more likely to have no access to psychiatrists. Rural communities were 6.65 (95% CI, 5.09-8.69) times more likely to have inadequate access to psychiatrists than urban communities. Conclusions and Relevance: In this cohort study of US communities, 35% of TRICARE beneficiaries lived in communities with inadequate access to psychiatrists. Psychiatric capacity was structurally inequitable along 2 separate dimensions: the income gradient and rurality. Developing targeted strategies for these shortage areas could alleviate disparities.

Differential Treatment and Outcomes for Patients With Heart Attacks in Advantaged and Disadvantaged Communities.

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.

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

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.

Effects of Iraq/Afghanistan deployments on major depression and substance use disorder: analysis of active duty personnel in the US military.

OBJECTIVES: Our objective was to analyze the association between deployment characteristics and diagnostic rates for major depression and substance use disorder among active duty personnel. METHODS: Using active duty personnel serving between 2001 and 2006 (n = 678,382) and deployment information from the Contingent Tracking System, we identified individuals diagnosed with substance use disorders and major depression from TRICARE health records. We performed logistic regression analysis to assess the effect of deployment location and length on these diagnostic rates. RESULTS: Increased odds of diagnosis with both conditions were associated with deployment to Iraq or Afghanistan compared with nondeployed personnel and with Army and Marine Corps personnel compared with Navy and Air Force personnel. Increases in the likelihood of either diagnosis with deployment length were only observed among Army personnel. CONCLUSIONS: There were increased substance use disorders and major depression across services associated with combat conditions. It would be important to assess whether the public health system has adequate resources to handle the increasing need of mental health services in this population.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States.

Importance: Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant. Objective: To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities. Design, Setting, and Participants: This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022. Main Outcomes and Measures: Hospitals' likelihood of adopting stroke care certification. Results: A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51). Conclusions and Relevance: In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Association between ambulance diversion and survival among patients with acute myocardial infarction.

CONTEXT: Ambulance diversion, a practice in which emergency departments (EDs) are temporarily closed to ambulance traffic, might be problematic for patients experiencing time-sensitive conditions, such as acute myocardial infarction (AMI). However, there is little empirical evidence to show whether diversion is associated with worse patient outcomes. OBJECTIVE: To analyze whether temporary ED closure on the day a patient experiences AMI, as measured by ambulance diversion hours of the nearest ED, is associated with increased mortality rates among patients with AMI. DESIGN, STUDY, AND PARTICIPANTS: A case-crossover design of 13,860 Medicare patients with AMI from 508 zip codes within 4 California counties (Los Angeles, San Francisco, San Mateo, and Santa Clara) whose admission date was between 2000 and 2005. Data included 100% Medicare claims data that covered admissions between 2000 and 2005, linked with date of death until 2006, and daily ambulance diversion logs from the same 4 counties. Among the hospital universe, 149 EDs were identified as the nearest ED to these patients. MAIN OUTCOME MEASURES: The percentage of patients with AMI who died within 7 days, 30 days, 90 days, 9 months, and 1 year from admission (when their nearest ED was not on diversion and when that same ED was exposed to <6, 6 to <12, and ≥12 hours of diversion out of 24 hours on the day of admission). RESULTS: Between 2000 and 2006, the mean (SD) daily diversion duration was 7.9 (6.1) hours. Based on analysis of 11,625 patients admitted to the ED between 2000 and 2005, and whose nearest ED had at least 3 diversion exposure levels (3541, 3357, 2667, and 2060 patients for no exposure, exposure to <6, 6 to <12, and ≥12 hours of diversion, respectively), there were no statistically significant differences in mortality rates between no diversion and exposure to less than 12 hours of diversion. Exposure to 12 or more hours of diversion was associated with higher 30-day mortality vs no diversion status (unadjusted mortality rate, 392 patients [19%] vs 545 patients [15%]; regression adjusted difference, 3.24 percentage points; 95% confidence interval [CI], 0.60-5.88); higher 90-day mortality (537 patients [26%] vs 762 patients [22%]; 2.89 percentage points; 95% CI, 0.13-5.64); higher 9-month mortality (680 patients [33%] vs 980 patients [28%]; 2.93 percentage points; 95% CI, 0.15-5.71); and higher 1-year mortality (731 patients [35%] vs 1034 patients [29%]; 3.04 percentage points; 95% CI, 0.33-5.75). CONCLUSION: Among Medicare patients with AMI in 4 populous California counties, exposure to at least 12 hours of diversion by the nearest ED was associated with increased 30-day, 90-day, 9-month, and 1-year mortality.