ER Closures & Mortality at Nearby Hospitals

There has been an increase in demand for emergency care in the U.S., yet access to emergency rooms is diminishing. From 1996 to 2009, annual visits to Emergency Departments (EDs) increased by 51% while the number of EDs decreased by 6%. This has led to increased crowding, wait times, and ambulance diversions in our emergency care system, ultimately delaying care for those patients who need it most.

Source: Bryan Mills (Flickr / CC)

ED closures pose a threat to the care of vulnerable populations. Studies have shown that communities with a larger proportion of racial and ethnic minorities, low income families, and those enrolled in Medicaid are at a heightened risk of losing their EDs. As growing health disparities further demarcate the line between the haves and have-nots, these closures only exacerbate this national public health problem.

While most studies have focused on the direct effects ED closures have on the immediate communities they once served, this study attempted to measure the impact extending to surrounding areas and patient populations. It examined the association between ED closures in California and inpatient mortality for all patients receiving care at hospitals located near EDs that closed. They found that admissions to a hospital near an ED closure had a 5% higher odds of inpatient mortality than those admissions at hospitals not near a closure.

There are several ways the effects of an ED closure can impact surrounding communities. The redistribution of patients causes increased crowding at nearby hospitals already strained by limited resources. Furthermore, increased travel time to these hospitals and/or delayed treatment of time-sensitive conditions adversely effects patient outcomes. Thus, the impact of ED closures can extend well beyond the areas they once served.

Researchers have shown that certain hospital characteristics, such as for-profit ownership and low profit margins, increased the risk of ED closures. With cost being a major factor, to what extent will we continue to allow market forces to limit access to care? This study elucidates the toll ED closures may have on the health of our communities. Several ideas have been proposed to prevent these closures including improved reimbursements rates, government subsidization, and federal regulation. Most importantly, it is time for emergency physicians to take lead in this debate, promote solutions, and become better advocates for our patients.

commentary by Thiago C. Halmer, MD, MBA

Dr. Halmer is a first year emergency medicine resident at Baylor College of Medicine. He recently graduated from the University of California, Irvine’s MD/MBA dual degree program, and is a former fellow of the Program in Medical Education for the Latino Community (PRIME-LC), UC Irvine School of Medicine’s signature program aimed at training physician leaders to become strong advocates for undeserved Latino populations.

Abstract

Between 1996 and 2009 the annual number of emergency department (ED) visits in the United States increased by 51 percent while the number of EDs nationwide decreased by 6 percent, which placed unprecedented strain on the nation’s EDs. To investigate the effects of an ED’s closing on surrounding communities, we identified all ED closures in California during the period 1999–2010 and examined their association with inpatient mortality rates at nearby hospitals. We found that one-quarter of hospital admissions in this period occurred near an ED closure and that these admissions had 5 percent higher odds of inpatient mortality than admissions not occurring near a closure. This association persisted whether we considered ED closures as affecting all future nearby admissions or only those occurring in the subsequent two years. These results suggest that ED closures have ripple effects on patient outcomes that should be considered when health systems and policymakers decide how to regulate ED closures. PMID: 25092832  Liu, C. et al. Health Affairs. 2014; 33 (8): 1323–1329.

Listen to the Podcast by Drs. Dark and Halmer discussing this article.