ED Closures and Openings Impact Morbidity and Mortality Rates

Since 2010, a total of 113 rural hospitals have closed in the U.S

Last week I was honored to be the opening keynote for SEACAA 2019; the annual conference for the Southeastern Association of Community Action Agencies. More than 1,000 of these agencies are on the front lines of the social determinants of health (SDoH), advocating for, coordinating, and partnering with populations in need to help ensure they receive necessary non-clinical services. They promote financial self-sufficiency through the following:

• Housing support
• Paying bills
• Early childhood education
• Homelessness prevention
• Hunger relief
• Healthy food access
• Transportation
• Job training
• Home weatherization

The agencies serving rural communities were front and center during the conference, as speakers emphasized the importance of recent studies focused on emergency department closures for these communities, as well as those in other areas impacted by the SDoH.

Rural Hospital Closures
Since 2010, a total of 113 rural hospitals have closed in the U.S., most of these in southern states. Another 430 hospitals are at risk. The ripple effect is unfathomable, leaving patients and their communities without appropriate acute care.

Some of you may have noticed a recent TV commercial. An ambulance crew tears into a hospital ED driveway with a critical patient onboard. They enter a dark, deserted ED space, with their next steps uncertain, although increased mortality risk to the patient is a given. 

From 2013 to 2017, rural hospitals closed at nearly double the rate of the previous five years, casualties of decreased reimbursement, increased healthcare costs, and a series of other factors. Appropriate care is now often at least 20 miles away, if not further, in these communities. In sum:

• 1 out of 5 rural hospitals are at risk of closure
• 64 percent of these facilities are essential to the health and economic well-being of their communities (often related to employment for the surrounding community)

One study conducted through the University of Washington examined 92 rural hospital closures in California. The most prominent impact was the increased morbidity and mortality rate for the populations served, as high as 5.9 percent, due to:

• Increased distances for residents to travel for care in emergency situations
• Missing the vital one-hour post-trauma treatment window for care and a more promising prognosis

Impact of ED Closures and Openings on Bystander Facilities
Another study funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) provided quite concerning results. The national study was the first to evaluate the impact of ED openings and closures on bystander EDs, looking specifically at outcomes for heart attack patients.

Medicare data from between 2001 to 2013 was pulled that examined treatment and health outcomes for over 1 million patients across 3,720 hospitals; the data included facilities and persons in rural areas. All facilities were affected by the closure or opening of an ED. The primary health outcomes measured were after 30 and 90 days, plus one-year mortality rates. Thirty-day readmissions were also reviewed. Findings included:

• Increased mortality with travel time of 30 minutes or more to get to another hospital
• One-year mortality rate for patients in those hospitals increased by 8 percent
• Thirty-day readmission rate increased by 6 percent 
• When an ED opened and driving time was reduced by 30 minutes, patients in bystander hospitals experienced a one-year mortality reduction of 5 percent
• The likelihood of these patients receiving cardiac procedures improved by 12 percent

The Impact on Women’s Health
Hospital and especially ED closures are impacting patient populations in all communities, particularly those individuals presenting with maternal health issues. The rate at which women die of pregnancy-related complications is 64 percent higher in rural areas compared to urban areas, and has been steadily rising. Over 700 women died within one year of giving birth, one study found,, double the maternal mortality rate of a decade ago. Increasing maternity deserts in cities have become an unhealthy norm.

Black women are disproportionately more likely to die during or after childbirth than white women, with three to four times the risk of mortality. Two wards of Washington, D.C, no longer have any hospitals with obstetric services. Pregnant women who live in these areas must travel as much as an hour or more for maternity care. When a woman has a high-risk pregnancy, or is at risk for premature birth, the outcomes can be often be fatal. More targeted funding, programs, and resources must be available to address these populations.

Programming Note: Follow this continuing story weekly on Monitor Mondays, 10-10:30 a.m. EST for the State of the Social Determinants report.