When EDs Close, Patients at Nearby Hospitals Suffer

Troy Brown, RN

September 06, 2019

When a hospital emergency department (ED) in one community closes, emergency care for patients in neighboring communities can suffer, especially at high-occupancy hospitals, new data show.

"ED closures don't affect all bystander hospitals equally; they affect the crowded ones more; and the same goes for ED openings," Renee Y. Hsia, MD, a professor of emergency medicine and health policy at the University of California, San Francisco, told Medscape Medical News.

The researchers used data from 2001 to 2013 to conduct a retrospective analysis in which they studied outcomes of patients who experienced an acute myocardial infarction at bystander EDs in areas in which nearby EDs had closed or opened.

When an ED closing increased a person's driving time to the nearest ED by at least 30 minutes and that ED was a high-occupancy facility, 1-year patient mortality rates rose, 30-day readmission rates increased, and a patient's likelihood of receiving percutaneous coronary intervention (PCI) fell.

On the other hand, when ED openings decreased driving times to high-occupancy bystander hospitals by at least 30 minutes, 30-day mortality at bystander hospitals decreased and a patient's likelihood of receiving PCI increased.

The study, by Hsia and Yu-Chu Shen, PhD, from the Graduate School of Business and Public Policy, Naval Postgraduate School, in Monterey, California, and the National Bureau of Economic Research, in Cambridge, Massachusetts,  was published online September 3 in Health Affairs.

Compared with patients at other bystander hospitals, a larger percentage of patients at high-occupancy bystander hospitals received catheterization (35% vs 51%), and a larger percentage of high-occupancy bystander hospitals had cardiac care units (50% vs 77%), catheterization laboratories (68% vs 92%), and the capacity to perform coronary artery bypass graft (40% vs 71%).

Among high-occupancy bystander hospitals, when ED closures increased the driving time by at least 30 minutes, 30-day and 1-year mortality rates for patients increased by 1.33 percentage points (95% confidence interval [CI], 0.50 – 2.15) and 3.23 percentage points (95% CI, 1.80 – 4.65), respectively. In addition, 30-day readmission rates rose by 1.52 percentage points (95% CI, 0.33 – 2.71).

Conversely, when ED openings reduced the driving time to a high-occupancy bystander hospital by at least 30 minutes, 30-day and 1-year mortality rates for patients fell by 3.40 percentage points (95% CI, −4.75 to −2.06) and 4.42 percentage points (95% CI, −6.11 to −2.73), respectively.

After adjusting for patient age and comorbid conditions, for patients treated in high-occupancy bystander hospitals where an ED closure had increased the driving time by at least 30 minutes, 30-day and 90-day mortality rates did not change significantly; however, for these patients, there were significant increases in 1-year mortality (3.12 percentage points; 95% CI, 2.18 – 4.06) and 30-day readmission rates (1.26 percentage points; 95% CI, 0.20 – 2.32).

After adjusting for patient age and comorbid conditions, when ED openings decreased driving time to the bystander hospital, the improvements in patient mortality rates were smaller but still significant (P < .01 for all mortality rates).

"Interestingly, when a non-high-occupancy bystander hospital was exposed to an ED closure that resulted in an increase of 30 minutes or more in driving time, the 1-year mortality rate improved by 5.64 percentage points (95% CI, −9.95 to −1.33) after we controlled for patient age and comorbidities," the researchers explain.

The authors note several study limitations, including their reliance on licensed beds to determine hospital occupancy rates, which might have overestimated occupancy. Also, the researchers used Google Maps to estimate driving time, and road and traffic conditions may have affected driving times at various times of day.

Hsia said ED closures most often occur "in poor and vulnerable communities. Unfortunately, I think the take-away to many people who aren't poor and aren't disadvantaged was a feeling of relief: 'Thank goodness that's not happening where I live.' But the findings of this research really do show us that our own access to quality healthcare is dependent on the ability of others to access quality healthcare as well."

The study also suggests it is possible to improve the system, Hsia explained.

Shen told Medscape Medical News, "While our focus is on cardiac outcomes, I believe our findings have broader implications for all patients, particularly in communities where inadequate health resources contribute to disproportionately poor health outcomes."

Shen emphasized, "[I]t is important to remember that our findings differ depending on whether the bystander hospital is a high- or low-occupancy hospital. The high-occupancy hospitals typically cared for a higher share of [socially and medically complex patients], so hospital closures around these high-occupancy hospitals would end up increasing the health disparity for vulnerable population[s] that our nation tries to mitigate."

The study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Health Aff. Published online September 3, 2019. Abstract

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