Impact of Rural and Urban Hospital Closures on Inpatient Mortality

Abstract

This paper uses a difference-in-difference approach to examine the impact of California's hospital closures occurring from 1995-2011 on adjusted inpatient mortality for time-sensitive conditions: sepsis, stroke, asthma/chronic obstructive pulmonary disease (COPD) and acute myocardial infarction (AMI). Outcomes of admissions in hospital service areas (HSAs) with and without closure(s) are compared before and after the closure year. The paper focuses on: 1) the differential impacts of rural and urban closures, 2) the aggregate patient-level impact across several post-closure mechanisms, and 3) the effect on Medicare as well as non-Medicare patients. Results suggest that when treatment groups are not differentiated by hospital rurality, closures appear to have no measurable impact, i.e. there is no general impact of closures. However, estimating differential impacts shows that rural closures increase inpatient mortality by 0.78% points (an increase of 8.7%), whereas urban closures have no measurable impact. Subgroup analyses indicate the existence of a general impact for stroke and AMI patients (4.4% increase in inpatient mortality) and relatively worse impacts of rural closures for Medicaid patients and racial minorities (11.3% and 12.6%, respectively).

The effect of rural hospital closures on emergency medical service response and transport times

“…Given evidence that minor delays in care for certain conditions can lead to a significant increase in mortality, 14,16 closures of rural hospitals could lead to mortality increases in affected communities. 20 Because of the importance of timely response, EMS records are designed to include granular details on the nature of the service. For example, key events in a typical call include the following: (a) call arrives at dispatch (9-1-1), which then notifies the EMS unit (ambulance); (b) EMS arrives at scene; (c) EMS arrives at patient side; (d) EMS leaves the scene; (e) EMS arrives at destination; and (f) EMS returns to service.…”

“…The average distance from a closed hospital to the next closest hospital in rural areas was 12 miles, which could lead to a considerable increase in time to care. Given evidence that minor delays in care for certain conditions can lead to a significant increase in mortality, closures of rural hospitals could lead to mortality increases in affected communities …”

The problems of smaller, rural and remote hospitals: Separating facts from fiction

“…This, in turn, leads to overcrowding and stretched services, with worsening of patient outcomes, for resource-intensive services such as emergency medicine and obstetrics. 87,88 Two Harvard studies found that closure of rural hospitals resulted in a 3% rise in 30-day mortality for patients overall and a 5% rise in 1-year mortality for time-sensitive conditions; there was no evidence of any cost savings from closures. 89,90 These findings were mirrored in a study of hospital closures in California, which found an increase in overall mortality, with changes in mortality differing by diagnostic condition.…”

Georgia Rural Hospital Tax Credit: Perspectives of Rural Health Executives

“…In Georgia alone, 7 rural hospitals have closed in the last 10 years, and 17 others are considered highly financially distressed and vulnerable to closure 2,3 . Hospital closures have a detrimental effect on the health and health‐seeking behavior of the population by decreasing access to care, 4 exacerbating dire economic conditions within communities, and worsening existing health disparities 5,6 …”