Health Policy and Health Services Research
Background: Hospital closures, including hospital-based emergency department (ED) closures, limit access to care and are associated with worse clinical outcomes. Little is known about national trends in ED closures based on health system consolidation. With this framework in mind, we characterize the trends in total number, geographic distribution, and size of EDs in the United States from 2006 to 2014.
Methods: Secondary analysis of the American Hospital Association (AHA) Annual Survey Database for the years 2006 through 2014. The Annual Survey Database is a proprietary dataset maintained by the AHA compiling results of an AHA-directed nationwide survey of all hospitals, data from the U.S. Census Bureau and hospital accrediting bodies. We included all short-term acute care hospitals providing general medical and surgical services while accounting for hospital closure, merger and new hospital openings. We defined a hospital-based ED as hospitals reporting an available ED. Hospitals were linked annually, and we defined an ED as open if at least two consecutive years were reported with >500 visits per year. An ED closure was defined as a hospital reporting an ED as open then subsequently reporting no ED as open for two consecutive years, or if the hospital closed. We defined urban-rural location according to US Census definitions, and ED visit volume. Trends in ED closures were characterized by year, urban-rural location, and ED visit volume. Chi-square tests were used to evaluate the hypothesis that the proportion of EDs closing in 2014 was higher than in 2006.
Results: From 2006 to 2014, the number of hospitals decreased from 4,768 to 4,632 and the number of EDs decreased from 4,650 to 4,531. Of the 213 EDs which closed over the time period, 211 were urban EDs and only 8 were rural ED closures. EDs with lower volume were more likely to close. 4.02% of EDs with volume 500-20,000 visits closed, while only 0.3% of EDs with volume >80,000 visits closed. The overall rate of ED closure was 4.5 / 1000 in 2006 compared to 8.1 / 1000 in 2014 (p-value for difference = 0.039).
Conclusion: While there are fewer EDs in 2014 than in 2006, the national number of ED closures has been modest. However, closures appear to disproportionately impact smaller EDs, warranting future research on the implications of hospital consolidation on geographic disparities in quality, cost, and access to emergency and acute care.