Between 1990 and 2009, the number of hospital emergency departments in nonrural areas across the United States declined by 27%, according to a report in the May 18 issue of JAMA.
"The closure of an ED can have profound repercussions for a community ... not only by increasing the distance to the nearest hospital but also by increasing the patient load at neighboring hospitals." This in turn degrades quality of care for insured and uninsured patients alike, prolonging wait times and raising both morbidity and mortality.
"ED closure can displace tens of thousands of uninsured and low-income patients to other EDs, worsening crowding and potentially setting the stage for additional closures," said Dr. Renee Y. Hsia of the department of emergency medicine at San Francisco General Hospital, and her associates.
They studied trends in ED closures using data on all general, acute, nonfederal, short-stay U.S. hospitals that participated in annual national surveys by the American Hospital Association. The investigators excluded rural hospitals from this study because they "are sometimes designated ‘critical access hospitals’ and operate under different federal mandates and supports" than do metropolitan hospitals.
Financial data were obtained from the Centers for Medicare and Medicaid Services’ Healthcare Cost Report Information System.
In 1990 there were 2,446 nonrural hospitals with EDs across the United States, which declined by 27% to 1,779 in 2009.
During that interval, 1,041 EDs closed. At the same time, 374 new EDs were opened, for a net loss of 667 nonrural EDs.
Most (66%) of the ED closures resulted from the closure of the entire hospital that operated the ED. But for the remaining 34%, EDs were closed while the hospitals remained open.
Four factors were associated with ED closure: for-profit ownership, location in a competitive market, low profit margin, and being a "safety-net" facility (that is, an ED that provides more than double the Medicare share, compared with competing hospitals within a 15-mile radius).
"The cumulative probability of an ED remaining open among safety-net hospitals was about 50%, compared with 74% among non–safety-net hospitals." This demonstrates that safety-net hospitals "require particular attention if emergency-care access is to be sustained," Dr. Hsia and her colleagues said (JAMA 2011;305:1978-85).
Similarly, "the cumulative probability for an ED to remain open was 50% among for-profit hospitals, compared with 75%" for not-for-profit and government-run hospitals.
As well, EDs at hospitals in the lowest quartile of profit margin had a 50% probability of remaining open, compared with a 75% probability among EDs at hospitals in the upper three quartiles.
And EDs at hospitals serving a high proportion of low-income patients had a lower probability of remaining open, compared with EDs at hospitals in more economically secure communities. "This could contribute to difficulty in recruiting and maintaining staff at all levels."
Moreover, the closure of EDs at such facilities is "especially compelling, given that vulnerable populations, including those in minority groups and both uninsured and underinsured patients, use EDs for acute care at greater rates than other populations," the researchers said.
Local market competition also was strongly associated with the likelihood that an ED would close. "Our study shows that market forces beyond profit margin alone are substantially related to the ability of an ED to remain open.
"Our findings underscore that market-based approaches to health care do not ensure that care will be equitably distributed. In fact, the opposite may be true.
"As long as tens of millions of Americans are uninsured, and tens of millions more pay well below their cost of care, the push for ‘results-driven competition’ will not correct system-level disparities that markets cannot – and should not – be expected to resolve," Dr. Hsia and her associates said.
This study was supported by the National Institutes of Health; the National Center for Research Resources; the University of California, San Francisco; and the Robert Wood Johnson Foundation. No financial conflicts of interest were reported.