Effect of Safety Net Hospital Closure on Local Physicians

Jennifer Garcia

November 14, 2011

November 14, 2011 — A large, publicly funded teaching hospital, Martin Luther King Hospital, in South Los Angeles, California, was closed in August 2007, shuttering a busy trauma center, emergency department, and residency training program. Researchers report in the November/December issue of the Annals of Family Medicine that the majority of primary care physicians interviewed (28/42) felt some negative effect of the closure on their patients and practices.

"The themes that emerged from these interviews describe a primary care workforce bearing the brunt of patient care without adequate patient care support," write study authors Kara Odom Walker, MD, MPH, MSHS, from the University of California, San Francisco, and colleagues.

The researchers note that physicians in both underserved and non-underserved settings felt the effects of the closure. In addition, however, although physicians whose practices were in close proximity to the hospital felt the effect of the closure most acutely, physicians whose practices were up to 20 miles away also felt its effect.

Previous research has examined the overall repercussions of safety net hospital closures, but few studies have examined the effect of such closures on primary care physicians. Therefore, a community advisory board composed of researchers, medical educators, physician leaders, and community clinic administrators designed the current study to assess the effect of the hospital's closing on healthcare providers.

Using a semistructured interview format, researchers asked local primary care physicians how the closure affected their practices. Question topics included, but were not limited to, the effect of the closure on admitting privileges, specialty care, elective surgery, teaching, and emergency care. The interviews were conducted between 6 and 13 months after the hospital closure.

The researchers interviewed 42 safety net and private practice physicians within and beyond the 12-mile estimated service area of Martin Luther King Hospital. The participating physicians ranged in age from 31 to 73 years, with a mean age of 48 years, and 45% were women. The majority of respondents specialized in either family medicine or internal medicine.

Researchers coded physician responses by recurring concepts, which were categorized based on dominant themes. Overall, Dr. Walker and colleagues identified 3 primary themes.

Increased Burden on Local and Regional Healthcare System

The hospital closure diminished the healthcare system's capacity, leading to decreased access to specialists, overcrowding, and poor continuity of care. Although this affected physicians in the underserved settings more acutely, the problems were also experienced by a third of the physicians in the non-underserved setting.

Referrals for elective surgeries were also more challenging after the hospital closure, resulting either in longer wait times or in sending patients to distant safety net hospitals.

As more patients were sent through emergency departments as a result of the lost admission privileges, physicians reported a loss of primary care linkages. Physicians outside the Martin Luther King Hospital system described overcrowding of emergency departments as the most significant change resulting from the closure.

Patients Had Difficulty Navigating the System of Care

Physicians reported seeing sicker patients, either because patients were unsure of where to go after the hospital closure or were unable to afford the increased transportation costs to go to a different facility.

A transitional plan for ambulatory care for Martin Luther King Hospital patients was in place; however, patients were unclear where to go, and transfer of care throughout the safety-net system failed, according to the physicians interviewed.

Workforce and Training Changes

Physicians reported that the hospital closure and loss of the residency training program led to fewer community primary care physicians and increased the strain on those who remained. Changes in workforce and training predominately affected physicians within the network of the closed safety net hospital.

The study authors acknowledge that semistructured interviews are sensitive to bias because of the qualitative nature of the data, and that the full range of issues arising from hospital closure may not have been addressed. They explain, however, that themes were consistent among physicians from diverse clinic settings and indicate that "[p]rimary care physicians should be informed and consulted when a major disruption to the health care delivery system is planned."

In an accompanying editorial, Robert L. Phillips, Jr, MD, MSPH, from the Robert Graham Center, Washington, DC, discusses the effect of the closure of the Martin Luther King Hospital and writes: "[I]t speaks to the unintended consequences that happen when we do not have the mind-set of community accountability."

He suggests that the Patient Protection and Affordable Care Act may help in addressing the closure of large safety net hospitals, noting that the act "requires that nonprofit hospitals assess their community and develop interventions based on that assessment every 3 years.... It is a start toward defining community and creating accountability for that community's health and well-being."

Dr. Walker received funding from the Robert Wood Johnson Foundation Clinical Scholars Program at the University of California, Los Angeles, and the University of California, Los Angeles, Resource Center for Minority Aging Research/Center for Health Improvement of Minority Elderly under the National Institutes of Health/National Institute on Aging, and the University of California, San Francisco, Center for Aging in Diversity Communities. Dr. Brown received support from the Beeson Career Development Award, the University of California, Los Angeles, Resource Center in Minority Aging Research, and the National Center on Minority Health and Health Disparities.

Ann Fam Med. 2011;9:496-503.

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