{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,3]],"date-time":"2026-10-03T02:54:05Z","timestamp":1790996045883,"version":"4.1.0"},"reference-count":40,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,2,12]],"date-time":"2025-02-12T00:00:00Z","timestamp":1739318400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"},{"start":{"date-parts":[[2025,2,12]],"date-time":"2025-02-12T00:00:00Z","timestamp":1739318400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["R01MD016426"],"award-info":[{"award-number":["R01MD016426"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["R01MD016426"],"award-info":[{"award-number":["R01MD016426"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["R01MD016426"],"award-info":[{"award-number":["R01MD016426"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["R01MD016426"],"award-info":[{"award-number":["R01MD016426"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["R01MD016426"],"award-info":[{"award-number":["R01MD016426"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sci Rep"],"DOI":"10.1038\/s41598-025-89983-1","type":"journal-article","created":{"date-parts":[[2025,2,12]],"date-time":"2025-02-12T14:56:23Z","timestamp":1739372183000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["A regional analysis of healthcare utilization trends during consecutive disasters in Puerto Rico using private claims data"],"prefix":"10.1038","volume":"15","author":[{"given":"Jim P.","family":"Stimpson","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Damaris Lopez","family":"Mercado","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra C.","family":"Rivera-Gonz\u00e1lez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan","family":"Purtle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander N.","family":"Ortega","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,2,12]]},"reference":[{"key":"89983_CR1","unstructured":"Office of the Assistant Secretary for Planning and Evaluation. Evidence Indicates a Range of Challenges for Puerto Rico Health Care System. (2017). https:\/\/aspe.hhs.gov\/reports\/evidence-indicates-range-challenges-puerto-rico-health-care-system"},{"key":"89983_CR2","unstructured":"Perreira, K., Lallemand, N., Napoles, A. & Zuckerman, S. Environmental Scan of Puerto Rico\u2019s Health Care Infrastructure. (2017). https:\/\/www.urban.org\/research\/publication\/environmental-scan-puerto-ricos-health-care-infrastructure"},{"key":"89983_CR3","unstructured":"KFF. Puerto Rico: Fast Facts. (2017). https:\/\/www.kff.org\/disparities-policy\/fact-sheet\/puerto-rico-fast-facts\/"},{"key":"89983_CR4","doi-asserted-by":"publisher","first-page":"112367","DOI":"10.1016\/j.socscimed.2019.112367","volume":"238","author":"J Benach","year":"2019","unstructured":"Benach, J., D\u00edaz, M. R., Mu\u00f1oz, N. J., Mart\u00ednez-Herrera, E. & Peric\u00e0s, J. M. What the Puerto Rican hurricanes make visible: Chronicle of a public health disaster foretold. Soc. Sci. Med. 238, 112367 (2019).","journal-title":"Soc. Sci. Med."},{"key":"89983_CR5","unstructured":"Roy, D. & Cheatham, A. Puerto Rico: A U.S. Territory in Crisis. (2025). https:\/\/www.cfr.org\/backgrounder\/puerto-rico-us-territory-crisis"},{"key":"89983_CR6","unstructured":"Currie, C. P. Puerto Rico Disasters: Progress Made, but the Recovery Continues to Face Challenges. (2024). https:\/\/www.gao.gov\/products\/gao-24-105557"},{"key":"89983_CR7","doi-asserted-by":"publisher","first-page":"162","DOI":"10.1056\/NEJMsa1803972","volume":"379","author":"N Kishore","year":"2018","unstructured":"Kishore, N. et al. Mortality in Puerto Rico after Hurricane Maria. N Engl. J. Med. 379, 162\u2013170 (2018).","journal-title":"N Engl. J. Med."},{"key":"89983_CR8","doi-asserted-by":"publisher","first-page":"e192619","DOI":"10.1001\/jamanetworkopen.2019.2619","volume":"2","author":"R Orengo-Aguayo","year":"2019","unstructured":"Orengo-Aguayo, R., Stewart, R. W., de Arellano, M. A., Su\u00e1rez-Kindy, J. L. & Young, J. Disaster exposure and Mental Health among Puerto Rican youths after Hurricane Maria. JAMA Netw. Open. 2, e192619 (2019).","journal-title":"JAMA Netw. Open."},{"key":"89983_CR9","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1017\/dmp.2018.103","volume":"13","author":"IM Ferr\u00e9","year":"2019","unstructured":"Ferr\u00e9, I. M. et al. Hurricane Maria\u2019s impact on Punta Santiago, Puerto Rico: Community needs and Mental Health Assessment six months Postimpact. Disaster Med. Public. Health Prep. 13, 18\u201323 (2019).","journal-title":"Disaster Med. Public. Health Prep"},{"key":"89983_CR10","doi-asserted-by":"publisher","first-page":"163","DOI":"10.1186\/s13690-024-01396-0","volume":"82","author":"D Burnette","year":"2024","unstructured":"Burnette, D., Kim, K. & Kim, S. Gender-related measurement invariance on the self-reporting questionnaire (SRQ-20) for global mental distress with older adults in Puerto Rico. Arch. Public. Health Arch. Belg. Sante Publique. 82, 163 (2024).","journal-title":"Arch. Public. Health Arch. Belg. Sante Publique"},{"key":"89983_CR11","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1017\/dmp.2018.151","volume":"13","author":"C Scaramutti","year":"2019","unstructured":"Scaramutti, C., Salas-Wright, C. P., Vos, S. R. & Schwartz, S. J. The Mental Health Impact of Hurricane Maria on Puerto ricans in Puerto Rico and Florida. Disaster Med. Public. Health Prep. 13, 24\u201327 (2019).","journal-title":"Disaster Med. Public. Health Prep"},{"key":"89983_CR12","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1186\/s41256-021-00228-w","volume":"6","author":"SL Rodr\u00edguez-Madera","year":"2021","unstructured":"Rodr\u00edguez-Madera, S. L. et al. The impact of Hurricane Maria on Puerto Rico\u2019s health system: post-disaster perceptions and experiences of health care providers and administrators. Glob Health Res. Policy. 6, 44 (2021).","journal-title":"Glob Health Res. Policy"},{"key":"89983_CR13","first-page":"10","volume":"9","author":"A Chandra","year":"2021","unstructured":"Chandra, A. et al. Health and Social Services in Puerto Rico before and after Hurricane Maria: Predisaster conditions, Hurricane damage, and themes for recovery. Rand Health Q. 9, 10 (2021).","journal-title":"Rand Health Q."},{"key":"89983_CR14","doi-asserted-by":"publisher","first-page":"e478","DOI":"10.1016\/S2542-5196(18)30209-2","volume":"2","author":"C Santos-Burgoa","year":"2018","unstructured":"Santos-Burgoa, C. et al. Differential and persistent risk of excess mortality from Hurricane Maria in Puerto Rico: a time-series analysis. Lancet Planet. Health. 2, e478\u2013e488 (2018).","journal-title":"Lancet Planet. Health"},{"key":"89983_CR15","doi-asserted-by":"publisher","first-page":"1367","DOI":"10.1007\/s10903-021-01310-8","volume":"24","author":"G Collazo","year":"2022","unstructured":"Collazo, G. et al. A retrospective cohort study on the Increasing Trend of Suicide Ideations and risks in an opioid-dependent Population of Puerto Rico 2015\u20132018. J. Immigr. Minor. Health. 24, 1367\u20131370 (2022).","journal-title":"J. Immigr. Minor. Health"},{"key":"89983_CR16","doi-asserted-by":"publisher","first-page":"1273","DOI":"10.3390\/ijerph21101273","volume":"21","author":"FI Rivera","year":"2024","unstructured":"Rivera, F. I. et al. Compound crises: the Impact of Emergencies and Disasters on Mental Health Services in Puerto Rico. Int. J. Environ. Res. Public. Health. 21, 1273 (2024).","journal-title":"Int. J. Environ. Res. Public. Health"},{"key":"89983_CR17","doi-asserted-by":"publisher","unstructured":"van der Elst, N., Hardebeck, J. & Michael, A. Potential Duration of Aftershocks of the 2020 Southwestern Puerto Rico Earthquake. (2020). https:\/\/doi.org\/10.3133\/ofr20201009","DOI":"10.3133\/ofr20201009"},{"key":"89983_CR18","doi-asserted-by":"publisher","first-page":"1413","DOI":"10.4269\/ajtmh.19-0015","volume":"100","author":"R Barrera","year":"2019","unstructured":"Barrera, R. et al. Impacts of hurricanes Irma and Maria on Aedes aegypti populations, aquatic habitats, and Mosquito infections with Dengue, Chikungunya, and Zika Viruses in Puerto Rico. Am. J. Trop. Med. Hyg. 100, 1413\u20131420 (2019).","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"89983_CR19","doi-asserted-by":"publisher","first-page":"763","DOI":"10.15585\/mmwr.mm7335a2","volume":"73","author":"FK Jones","year":"2024","unstructured":"Jones, F. K. et al. Leptospirosis Outbreak in Aftermath of Hurricane Fiona \u2014 Puerto Rico, 2022. MMWR Morb Mortal. Wkly. Rep. 73, 763\u2013768 (2024).","journal-title":"MMWR Morb Mortal. Wkly. Rep."},{"key":"89983_CR20","doi-asserted-by":"publisher","first-page":"e263","DOI":"10.1093\/geronb\/gbaa186","volume":"76","author":"C Garc\u00eda","year":"2021","unstructured":"Garc\u00eda, C., Rivera, F. I., Garcia, M. A., Burgos, G. & Aranda, M. P. Contextualizing the COVID-19 era in Puerto Rico: compounding disasters and parallel pandemics. J. Gerontol. B Psychol. Sci. Soc. Sci. 76, e263\u2013e267 (2021).","journal-title":"J. Gerontol. B Psychol. Sci. Soc. Sci."},{"key":"89983_CR21","doi-asserted-by":"publisher","first-page":"325","DOI":"10.1111\/1475-6773.14092","volume":"58","author":"J Purtle","year":"2023","unstructured":"Purtle, J. et al. Growing inequities in mental health crisis services offered to indigent patients in Puerto Rico versus the US states before and after hurricanes Maria and Irma. Health Serv. Res. 58, 325\u2013331 (2023).","journal-title":"Health Serv. Res."},{"key":"89983_CR22","doi-asserted-by":"publisher","first-page":"103279","DOI":"10.1016\/j.ijdrr.2022.103279","volume":"82","author":"I Garcia","year":"2022","unstructured":"Garcia, I. et al. Health-related nonprofit response to concurrent disaster events. Int. J. Disaster Risk Reduct. 82, 103279 (2022).","journal-title":"Int. J. Disaster Risk Reduct."},{"key":"89983_CR23","unstructured":"Cruz, N. I., Santiago, E. & Alers, R. I. The COVID-19 Pandemic and the Surgical Workload of the UPR-affiliated Hospitals. 42, (2023)."},{"key":"89983_CR24","doi-asserted-by":"publisher","first-page":"418","DOI":"10.1017\/S1049023X18000638","volume":"33","author":"EC Smith","year":"2018","unstructured":"Smith, E. C., Burkle, F. M., Aitken, P. & Leggatt, P. Seven decades of disasters: a systematic review of the literature. Prehospital Disaster Med. 33, 418\u2013423 (2018).","journal-title":"Prehospital Disaster Med."},{"key":"89983_CR25","doi-asserted-by":"publisher","first-page":"169","DOI":"10.1146\/annurev-publhealth-032013-182435","volume":"35","author":"E Goldmann","year":"2014","unstructured":"Goldmann, E. & Galea, S. Mental Health consequences of disasters. Annu. Rev. Public. Health. 35, 169\u2013183 (2014).","journal-title":"Annu. Rev. Public. Health"},{"key":"89983_CR26","doi-asserted-by":"publisher","first-page":"e430","DOI":"10.1017\/dmp.2023.93","volume":"17","author":"JP Stimpson","year":"2023","unstructured":"Stimpson, J. P., Mercado, D. L., Rivera-Gonz\u00e1lez, A. C. & Ortega, A. N. Trends in routine checkup within the past year following a hurricane. Disaster Med. Public. Health Prep. 17, e430 (2023).","journal-title":"Disaster Med. Public. Health Prep"},{"key":"89983_CR27","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1016\/j.jadohealth.2024.08.019","volume":"76","author":"P Campbell","year":"2025","unstructured":"Campbell, P., Edwards, B. & Gray, M. Exposure to multiple natural disasters and externalising and internalising behavior: a longitudinal study of adolescents. J. Adolesc. Health. 76, 89\u201395 (2025).","journal-title":"J. Adolesc. Health"},{"key":"89983_CR28","doi-asserted-by":"publisher","first-page":"658","DOI":"10.1186\/s12888-024-06078-3","volume":"24","author":"T Barlattani","year":"2024","unstructured":"Barlattani, T. et al. Patterns of psychiatric admissions across two major health crises: L\u2019 Aquila earthquake and COVID-19 pandemic lockdown. BMC Psychiatry. 24, 658 (2024).","journal-title":"BMC Psychiatry"},{"key":"89983_CR29","doi-asserted-by":"publisher","first-page":"749","DOI":"10.3390\/ijerph21060749","volume":"21","author":"ST Johnson","year":"2024","unstructured":"Johnson, S. T., Mason, S. M., Erickson, D., Slaughter-Acey, J. C. & Waters, M. C. Predicting Post-disaster post-traumatic stress disorder symptom trajectories: the role of Pre-disaster traumatic experiences. Int. J. Environ. Res. Public. Health. 21, 749 (2024).","journal-title":"Int. J. Environ. Res. Public. Health"},{"key":"89983_CR30","doi-asserted-by":"publisher","first-page":"115888","DOI":"10.1016\/j.socscimed.2023.115888","volume":"325","author":"N Varas-D\u00edaz","year":"2023","unstructured":"Varas-D\u00edaz, N. et al. On leaving: coloniality and physician migration in Puerto Rico. Soc. Sci. Med. 325, 115888 (2023).","journal-title":"Soc. Sci. Med."},{"key":"89983_CR31","doi-asserted-by":"publisher","first-page":"485","DOI":"10.1080\/09581596.2021.1998376","volume":"32","author":"M Padilla","year":"2022","unstructured":"Padilla, M. et al. Red tape, slow emergency, and chronic disease management in post-Mar\u00eda Puerto Rico. Crit. Public. Health. 32, 485\u2013498 (2022).","journal-title":"Crit. Public. Health"},{"key":"89983_CR32","doi-asserted-by":"publisher","first-page":"1118","DOI":"10.1038\/s41591-024-02833-x","volume":"30","author":"RN Salas","year":"2024","unstructured":"Salas, R. N. et al. Impact of extreme weather events on healthcare utilization and mortality in the United States. Nat. Med. 30, 1118\u20131126 (2024).","journal-title":"Nat. Med."},{"key":"89983_CR33","unstructured":"Coss-Guzm\u00e1n, M. & Rom\u00e1n-V\u00e1zquez, N. Informe Mensual de Suicidios En Puerto Rico. (2021)."},{"key":"89983_CR34","doi-asserted-by":"publisher","first-page":"17849","DOI":"10.1038\/s41598-024-69055-6","volume":"14","author":"JP Stimpson","year":"2024","unstructured":"Stimpson, J. P. et al. Trends in hospital capacity and utilization in Puerto Rico by health regions, 2010\u20132020. Sci. Rep. 14, 17849 (2024).","journal-title":"Sci. Rep."},{"key":"89983_CR35","unstructured":"Major Hurricane Maria - September 20, (2017). https:\/\/www.weather.gov\/sju\/maria2017 (2017)."},{"key":"89983_CR36","unstructured":"Private Health Insurance Coverage by Type and & Characteristics, S. U.S. Census Bureau (2023)."},{"key":"89983_CR37","unstructured":"Plans in Compliance with the Affordable Care Act and the Health Insurance Code. (2025). https:\/\/www.ocs.pr.gov\/en-us\/seguros-de-salud\/cubiertas\/2025\/cubiertas-individuales"},{"issue":"Suppl 2","key":"89983_CR38","doi-asserted-by":"publisher","first-page":"172","DOI":"10.1111\/1475-6773.14036","volume":"57","author":"AC Rivera-Gonz\u00e1lez","year":"2022","unstructured":"Rivera-Gonz\u00e1lez, A. C. et al. The impact of Medicaid funding structures on inequities in health care access for latinos in New York, Florida, and Puerto Rico. Health Serv. Res. 57 (Suppl 2), 172\u2013182 (2022).","journal-title":"Health Serv. Res."},{"key":"89983_CR39","doi-asserted-by":"publisher","first-page":"e2446523","DOI":"10.1001\/jamanetworkopen.2024.46523","volume":"7","author":"AC Rivera-Gonz\u00e1lez","year":"2024","unstructured":"Rivera-Gonz\u00e1lez, A. C., Purtle, J., Kaholokula, J. K., Stimpson, J. P. & Ortega, A. N. Maui Wildfire and 988 suicide and Crisis Lifeline call volume and capacity. JAMA Netw. Open. 7, e2446523 (2024).","journal-title":"JAMA Netw. Open."},{"key":"89983_CR40","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1097\/DMP.0b013e318183cfbb","volume":"2","author":"JP Stimpson","year":"2008","unstructured":"Stimpson, J. P., Wilson, F. A. & Jeffries, S. K. Seeking help for disaster services after a flood. Disaster Med. Public. Health Prep. 2, 139\u2013141 (2008).","journal-title":"Disaster Med. Public. Health Prep"}],"container-title":["Scientific Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41598-025-89983-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-025-89983-1","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-025-89983-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,14]],"date-time":"2025-03-14T22:07:20Z","timestamp":1741990040000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41598-025-89983-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,12]]},"references-count":40,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["89983"],"URL":"https:\/\/doi.org\/10.1038\/s41598-025-89983-1","relation":{},"ISSN":["2045-2322"],"issn-type":[{"value":"2045-2322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,2,12]]},"assertion":[{"value":"13 October 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 February 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"12 February 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}},{"value":"This study analyzed publicly available data about hospital characteristics aggregated at the health region level. Therefore, this study was not considered to be human subjects research by the University of Puerto Rico Medical Sciences Campus institutional review board.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}}],"article-number":"5249"}}