Interfacility Transfer of Uninsured vs Insured Patients With ST-Segment Elevation Myocardial Infarction in California

Impact of Hispanic Ethnicity, Geography, and Insurance Status on Cardiovascular Outcomes in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Hispanics are the largest and fastest growing ethnic minority population in the United States yet are poorly represented in cardiovascular outcomes studies. UC San Diego Health is a primary percutaneous coronary intervention (PCI) center for a diverse group of patients given its proximity to Mexico and underserved rural southeast Imperial County.

OBJECTIVES

The purpose of this study was to study the association between Hispanic ethnicity, geography, insurance status, and PCI outcomes.

METHODS

The UC San Diego Health internal National Cardiovascular Data Registry CathPCI Registry was used to obtain data on patients who underwent PCI from January 2007 to September 2022. Complications and all-cause mortality within 1-year post-PCI were assessed.

RESULTS

A total of 8,295 patients (age 66 years [IQR: 58-75 years], 72% male, 33% Hispanic ethnicity, and 30% from Imperial County) were included. Hispanics and patients from Imperial County irrespective of race or ethnicity had higher body mass index and were more likely to have diabetes, hypertension, hyperlipidemia, end-stage renal disease, and peripheral vascular disease. There was no difference in mortality rates between Hispanic and non-Hispanic Whites in the entire population. However, within Imperial County, Hispanics had significantly higher 30-day (1.4% vs 0.3% P = 0.02), 6-month (2.2% vs 0.8% P = 0.01), and 1-year (2.9% vs 0.9% P = 0.004) mortality rates compared to non-Hispanic Whites. Patients in Imperial County had lower 30-day (1.2% vs 1.9% P = 0.01), 6-month (1.9% vs 3.3% P < 0.001), and 1-year (2.4% vs 5% P < 0.001) mortality rates compared to patients outside of Imperial County. There was no difference in all-cause mortality rates by insurance status in non-Hispanic Whites. Uninsured Hispanic patients had a higher 30-day mortality rate compared to Hispanic patients who had Medicare/Medicaid or private insurance (4.5% vs 2.0% vs 1.0% P = 0.005). Within Imperial County, uninsured Hispanic patients had markedly higher 30-day mortality rate compared to Hispanic patients who had Medicare/Medicaid or private insurance (10.4% vs 1.6% vs 0.3% P < 0.001).

CONCLUSIONS

In socioeconomically disadvantaged areas, Hispanic patients had worse outcomes compared to non-Hispanic Whites compounded by uninsured status. There are complex demographic disparities in PCI outcomes for Hispanic patients and those residing in border zones which need to be recognized and mitigated.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Trends in Patient Transfers From Overall and Caseload-Strained US Hospitals During the COVID-19 Pandemic

Importance

Transferring patients to other hospitals because of inpatient saturation or need for higher levels of care was often challenging during the early waves of the COVID-19 pandemic. Understanding how transfer patterns evolved over time and amid hospital overcrowding could inform future care delivery and load balancing efforts.

Objective

To evaluate trends in outgoing transfers at overall and caseload-strained hospitals during the COVID-19 pandemic vs prepandemic times.

Design, Setting, and Participants

This retrospective cohort study used data for adult patients at continuously reporting US hospitals in the PINC-AI Healthcare Database. Data analysis was performed from February to July 2023.

Exposures

Pandemic wave, defined as wave 1 (March 1, 2020, to May 31, 2020), wave 2 (June 1, 2020, to September 30, 2020), wave 3 (October 1, 2020, to June 19, 2021), Delta (June 20, 2021, to December 18, 2021), and Omicron (December 19, 2021, to February 28, 2022).

Main Outcomes and Measures

Weekly trends in cumulative mean daily acute care transfers from all hospitals were assessed by COVID-19 status, hospital urbanicity, and census index (calculated as daily inpatient census divided by nominal bed capacity). At each hospital, the mean difference in transfer counts was calculated using pairwise comparisons of pandemic (vs prepandemic) weeks in the same census index decile and averaged across decile hospitals in each wave. For top decile (ie, high-surge) hospitals, fold changes (and 95% CI) in transfers were adjusted for hospital-level factors and seasonality.

Results

At 681 hospitals (205 rural [30.1%] and 476 urban [69.9%]; 360 [52.9%] small with <200 beds and 321 [47.1%] large with ≥200 beds), the mean (SD) weekly outgoing transfers per hospital remained lower than the prepandemic mean of 12.1 (10.4) transfers per week for most of the pandemic, ranging from 8.5 (8.3) transfers per week during wave 1 to 11.9 (10.7) transfers per week during the Delta wave. Despite more COVID-19 transfers, overall transfers at study hospitals cumulatively decreased during each high national surge period. At 99 high-surge hospitals, compared with a prepandemic baseline, outgoing acute care transfers decreased in wave 1 (fold change -15.0%; 95% CI, -22.3% to -7.0%; P < .001), returned to baseline during wave 2 (2.2%; 95% CI, -4.3% to 9.2%; P = .52), and displayed a sustained increase in subsequent waves: 19.8% (95% CI, 14.3% to 25.4%; P < .001) in wave 3, 19.2% (95% CI, 13.4% to 25.4%; P < .001) in the Delta wave, and 15.4% (95% CI, 7.8% to 23.5%; P < .001) in the Omicron wave. Observed increases were predominantly limited to small urban hospitals, where transfers peaked (48.0%; 95% CI, 36.3% to 60.8%; P < .001) in wave 3, whereas large urban and small rural hospitals displayed little to no increases in transfers from baseline throughout the pandemic.

Conclusions and Relevance

Throughout the COVID-19 pandemic, study hospitals reported paradoxical decreases in overall patient transfers during each high-surge period. Caseload-strained rural (vs urban) hospitals with fewer than 200 beds were unable to proportionally increase transfers. Prevailing vulnerabilities in flexing transfer capabilities for care or capacity reasons warrant urgent attention.

Initial treatment of uninsured patients with ST-elevation myocardial infarction by facility percutaneous coronary intervention capabilities

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.