Economic factors linked to increase in ED closures

The number of hospital EDs in nonrural areas across the United States has decreased by 27% during a 20-year period, according to data recently published in the Journal of the American Medical Association.

“ED closures can have substantial effects on vulnerable communities, causing a decline in care as hospitals serving poor and minority populations select to provide services based on profitability rather than community health needs,” the researchers wrote.

They gathered data on general, acute, nonrural, short-stay hospitals in the United States from the American Hospital Association Annual Surveys from 1990 to 2009, along with hospital financial and payer mix information through 2007 from Medicare hospital cost reports. Three sets of risk factors for closure were examined: hospital characteristics, county population demographics and market factors. Safety-net hospitals were defined as those caring for more than double their Medicaid share of discharges compared with other hospitals in a 15-mile radius, according to the study.

During the study period, the number of EDs decreased from 2,446 to 1,779 (27%), with an average of 89 EDs closing per year. Between 1999 and 2007, for-profit hospital EDs were more likely to be closed than EDs that remained open (26% vs. 16%). For-profit hospitals or those with low profit margins were more likely to close compared with their counterparts (HR=1.8; 95% CI, 1.5-2.1 and HR=1.9; 95% CI, 1.6-2.3). EDs that closed were also more likely to be in areas with high minority populations (36% vs. 31%), high poverty populations (37% vs. 31%) and more than 15% of patients without insurance (42% vs. 36%). More EDs in highly competitive markets closed compared with EDs that did not close (34% vs. 17%).

Three characteristics were associated with an increased risk for ED closures, according to adjusted analysis: safety-net status, for-profit status and those hospitals with profit margins in the lowest quartile. EDs located within a 15-mile radius of another ED and those hospitals in areas with high levels of competition were at a higher risk for closure.

“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,” the researchers wrote.

For more information:

Hsia RY. JAMA. 2011;305:1978-1985.

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