Emergency department closures can affect death rates, finds UCSF research

In the first analysis of its kind, UC San Francisco research shows that emergency department closures can have a ripple effect on patient outcomes at nearby hospitals.

In a study of more than 16 million emergency admissions to California hospitals between 1999 and 2010, researchers found that patients who were admitted to facilities located in the vicinity of an emergency department (ED) that had recently closed experienced 5 percent higher odds of dying than patients admitted to hospitals that were not near a recently closed ED.

The odds of dying were even higher for patients with certain time-sensitive conditions, especially heart attack (15 percent higher odds), stroke (10 percent) and sepsis (8 percent). The findings are of particular concern nationwide, said the authors, because the annual number of ED visits increased by 51 percent between 1996 and 2009, while the number of available emergency departments dropped by 6 percent.

The report will be published in the August issue of Health Affairs.

"Emergency department closures are affecting many more patients than previously thought," said senior author Renee Y. Hsia, MD, an associate professor of emergency medicine at UCSF and director of health policy studies in the department of emergency medicine. She is also an attending physician in the emergency department at San Francisco General Hospital and Trauma Center. "Most importantly, people who live in the area of nearby closures but whose own hospital did not close are still negatively affected by increased wait times and crowding in their own emergency department," she said.

In recent years, the nation's emergency departments have experienced an unprecedented strain with approximately 130 million annual visits according to the Centers for Disease Control and Prevention. While the number of patient visits has soared, the number of EDs nationally declined 6 percent to 4,594 between 1996 and 2009.

To investigate the effects of closures on surrounding communities, the authors analyzed the association between inpatient mortality rates at hospitals located near emergency departments in California that closed between 1999 and 2010. During this timeframe, 48 emergency departments were shuttered in the state.

The researchers found that ED closures affected nearly a quarter of admissions during the study period. Previous research has shown that patient mortality rates can increase with longer travel or wait times and crowding at emergency rooms. Furthermore, ED closures could also cause some patients to delay seeking medical care and could lead to conditions becoming less treatable.

As a result, ED closures could further reduce access to care in communities with vulnerable populations, said the authors.

"Our findings indicate that disproportionate numbers of ED closures may be driving up inpatient mortality in communities and hospitals with more minority, Medicaid and low-income patients, and contributing to existing disparities in health outcomes," said Hsia. "These results suggest that health systems and policy makers should consider the ripple effect on communities when they regulate ED closures."

The study data were obtained from the California Office of Statewide Health Planning and Development's Hospital Annual Utilization Data files.