Effects of increased distance to urgent and emergency care facilities resulting from health services reconfiguration: a systematic review

Abstract

Background Service reconfigurations sometimes increase travel time and/or distance for patients to reach their nearest hospital or other urgent and emergency care facility. Many communities value their local services and perceive that proposed changes could worsen outcomes for patients. Objectives To identify, appraise and synthesise existing research evidence regarding the outcomes and impacts of service reconfigurations that increase the time and/or distance for patients to reach an urgent and emergency care facility. We also aimed to examine the available evidence regarding associations between distance to a facility and outcomes for patients and health services, together with factors that may influence (moderate or mediate) these associations. Data sources We searched seven bibliographic databases in February 2019. The search was supplemented by citation-tracking and reference list checking. A separate search was conducted to identify the current systematic reviews of telehealth to support urgent and emergency care. Methods Brief inclusion and exclusion criteria were as follows: (1) population – adults or children with conditions that required emergency treatment; (2) intervention/comparison – studies comparing outcomes before and after a service reconfiguration, which affects the time/distance to urgent and emergency care or comparing outcomes in groups of people travelling different distances to access urgent and emergency care; (3) outcomes – any patient or health system outcome; (4) setting – the UK and other developed countries with relevant health-care systems; and (5) study design – any. The search results were screened against the inclusion criteria by one reviewer, with a 10% sample screened by a second reviewer. A quality (risk-of-bias) assessment was undertaken using The Joanna Briggs Institute Checklist for Quasi-Experimental Studies. We performed a narrative synthesis of the included studies and assessed the overall strength of evidence using a previously published method. Results We included 44 studies in the review, of which eight originated from the UK. For studies of general urgent and emergency care populations, there was no evidence that reconfiguration that resulted in increased travel time/distance affected mortality rates. By contrast, evidence of increased risk was identified from studies restricted to patients with acute myocardial infarction. Increases in mortality risk were most obvious within the first 1–4 years after reconfiguration. Evidence for other conditions was inconsistent or very limited. In the absence of reconfiguration, evidence mainly from cohort studies indicated that increased travel time or distance is associated with increased mortality risk for the acute myocardial infarction and trauma populations, whereas for obstetric emergencies the evidence was inconsistent. We included 12 systematic reviews of telehealth. Meta-analyses suggested that telehealth technologies can reduce time to treatment for people with stroke and ST elevation myocardial infarction. Limitations Most studies came from non-UK settings and many were at high risk of bias because there was no true control group. Most review processes were carried out by a single reviewer within a constrained time frame. Conclusions We found no evidence that increased distance increases mortality risk for the general population of people requiring urgent and emergency care, although this may not be true for people with acute myocardial infarction or trauma. Increases in mortality risk were most likely in the first few years after reconfiguration. Future work Research is needed to better understand how health systems plan for and adapt to increases in travel time, to quantify impacts on health system outcomes, and to address the uncertainty about how risk increases with distance in circumstances relevant to UK settings. Study registration This study is registered as PROSPERO CRD42019123061. Funding This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 31. See the NIHR Journals Library website for further project information.

Centralization of emergency hospital care is not associated with increased in-hospital mortality; a population-based cohort study

“…Our study's results show a consistent reduction in in-hospital mortality across municipality groups, suggesting that if the reconfiguration has affected mortality, this has occurred uniformly across municipalities, irrespective of emergency hospital status. Like other studies, 8,23,24 our results suggest that AMI contacts in municipalities with increased distance to emergency departments have not experienced the improved mortality documented for other contacts-suggesting that residents living the farthest away from an acute hospital do not achieve the improvement effects that closer residents benefit from. Patient trajectories are very complex, and our study does not point to whether a problem might be present for AMI contacts.…”

“…12 In terms of the effect of increased distance travelled to emergency departments seen in this study, previous studies have shown that increased distance to emergency departments is not associated with increased mortality in the general population requiring emergency care. 23,24 The only exceptions were acute myocardial infarcts and trauma, for which the risk of mortality increased for both groups in the first few years after reorganization. 23,24 Fløjstrup et al have documented a downward trend in the in-hospital mortality in Denmark, which is consistent with this study's results.…”

“…23,24 The only exceptions were acute myocardial infarcts and trauma, for which the risk of mortality increased for both groups in the first few years after reorganization. 23,24 Fløjstrup et al have documented a downward trend in the in-hospital mortality in Denmark, which is consistent with this study's results. Our study's results show a consistent reduction in in-hospital mortality across municipality groups, suggesting that if the reconfiguration has affected mortality, this has occurred uniformly across municipalities, irrespective of emergency hospital status.…”

A systematic review case study of urgent and emergency care configuration found citation searching of Web of Science and Google Scholar of similar value

“…Citation searching offers a potential response to such search challenges. The exemplar systematic review showcased in this study was undertaken over 7 months, between January and July 2019 (Chambers, Cantrell, et al, 2020).…”