Health policy/original researchIs Emergency Department Closure Resulting in Increased Distance to the Nearest Emergency Department Associated With Increased Inpatient Mortality?
Introduction
In 2006, the Institute of Medicine reported that “the emergency care system of the future should be highly regionalized, coordinated, and accountable.”1 Although purposeful and nationwide regionalization has yet to materialize into health policy,2 current changes in emergency department (ED) distribution provide an opportunity to study the natural experiment of ED closures and the subsequent effects on patients to inform regionalization initiatives or other health policies aiming to restructure health care delivery systems.3
During the last 2 decades, the annual number of ED visits nationwide increased from 94.9 million to 116.8 million (23%) amidst a concurrent decrease in the number of EDs from 4,114 to 3,925 (4.6%).4 The trend in California is even more striking, where there has been a 12% reduction in available EDs and a 27% increase in total patient visits per ED.5, 6, 7, 8, 9 Increased ED demand in a setting of progressive ED closures—which disproportionately occur in underserved areas10—has stirred significant public and media concern.11
ED closure is important because it may increase the distance and time it takes for patients to access critical medical care. Increased geographic distance affects people's willingness to seek care.12, 13 One study of hospital closure in Los Angeles demonstrated that even a 1-mile increase in hospital proximity is associated with a 6.5% increase in the death rate from acute myocardial infarction and an 11% to 20% increase from unintentional injuries.14 However, this study was done with aggregated outcomes rather than patient-level outcomes. Another study in Los Angeles found that hospital closure caused a transient increase in crowding and ambulance diversions for surrounding EDs,15 which have both been related to adverse patient outcomes.16, 17
There is limited literature evaluating the effect of ED closure on clinically relevant patient health outcomes and little known about the extent to which people are affected by closures. Defining such effects may provide policymakers with a clearer picture of the effect of closure as they propose changes in acute care systems, especially given the federal emphasis on regionalization.1 In this study, we sought to first quantify the proportion of patients who, during an 11-year period, experienced an increase in distance to their nearest ED and the extent to which they were affected. Our main goal was to determine whether patients who experienced increases in distance to their nearest ED also experienced increased inpatient mortality. Specifically, we hypothesized that these increases in distance would be associated with poorer outcomes for 4 time-sensitive medical conditions: acute myocardial infarction, stroke, sepsis, and asthma or chronic obstructive pulmonary disease. We sought to evaluate whether patients with these prespecified time-sensitive conditions had a higher risk of inpatient mortality when evaluated as an overall cohort together, as well as separately, in analyses stratified by condition.
Section snippets
Study Design and Setting
Using data from nonfederal hospitals in California, we performed a nonconcurrent cohort study of all admissions for conditions that have been previously identified as time-sensitive18, 19, 20, 21, 22: acute myocardial infarction, stroke, sepsis, and asthma or chronic obstructive pulmonary disease, according to the Clinical Classifications Software from the Agency for Healthcare Quality and Research.23
We used nonpublic patient-level data for admitted adult patients from January 1, 1999, to
Results
We studied a total of 785,385 patients during this period (Table 1), of which 67,577 (8.6%) individuals experienced an increase in distance to their nearest ED. The increase in distance experienced by patients ranged from as little as 0.1 to as great as 33.4 miles, with a median of 0.8 miles. As shown in Table 2, the medians were identical when analyzed by disease condition. Patients experiencing a decrease had a greater distance change than those experiencing an increase; overall, patients who
Limitations
Our study has several notable limitations. First, our primary outcome was inhospital mortality, which, although having strong face validity, remains a crude indicator of adverse outcomes related to delays in emergency care, relative to endpoints such as survival to longer periods or clinical outcome measures such as angina, ejection fraction, or functional status. It is possible that small changes in distance and time are more likely to affect morbidity than mortality, but this effect remains
Discussion
In this study of California EDs, closures that produced longer distances to emergency care were not associated with higher odds for inpatient mortality across a range of time-sensitive conditions. Our results are contrary to our initial hypothesis that mortality would worsen when the distance to emergency care increases. Despite strong evidence for early treatment of many acute conditions, these findings raise several interesting possible explanations.
First, only a small percentage—less than
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Cited by (21)
Impact of temporary closures of emergency departments during the COVID-19 outbreak on clinical outcomes for emergency patients in a metropolitan area
2021, American Journal of Emergency MedicineCitation Excerpt :Consecutive and concurrent shutdowns of multiple EDs can affect the regional emergency medical services (EMS) system and change the health behavior of emergency care access for patients with critical illnesses or intensive care needs, which can lead to changes in clinical outcomes [9,10]. Previous studies have demonstrated the effects of closure or downgrades of regional EDs, as well as trauma centers, on the long-term outcomes for patients with time-sensitive illnesses, such as acute myocardial infarction (AMI) and severe trauma [10-13]. However, there have been no reports on the impact of concurrent short-term ED closures in pandemic or disaster situations on the clinical outcomes of emergency patients.
THE ACUTE CARE CONTINUUM IN CALIFORNIA
2017, Revista Medica Clinica Las CondesTowards more realistic measures of accessibility to emergency departments in Sweden
2024, International Journal of Health GeographicsEfficiency effects of public hospital closures in the context of public hospital reform: a multistep efficiency analysis
2024, Health Care Management Science
Please see page 708 for the Editor's Capsule Summary of this article.
Supervising editor: Donald M. Yealy, MD
Author contributions: RYH, CM, and ADA were responsible for study concept and design. RYH and JM were responsible for acquisition of data. All authors were responsible for analysis and interpretation of the data, critical revision of the article for important intellectual content, and administrative, technical, and material support. RYH and HKK drafted the article. TS and JM were responsible for statistical analysis. RYH and ADA obtained funding. RYH, CM, and ADA were responsible for study supervision. RYH takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This research was supported by NIH/NCRR/OD UCSF-CTSI grant KL2 RR024130 (Dr. Hsia), the Robert Wood Johnson Foundation Physician Faculty Scholars (Dr. Hsia), and NIH/NHLBI grant K24HL098372 (Dr. Auerbach). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of any of the funding agencies.
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Publication date: Available online September 29, 2012.