The Health Affairs article, “California Emergency Department Closures Are Associated With Increased Inpatient Mortality At Nearby Hospitals,” by Charles Liu, Tanja Srebotnjak, and Renee Y. Hsia, recently published in the August issue, presents an important, timely, and well-conceived analysis, especially given the number of emergency department (ED) closures in the last 10-15 years, the concomitant rise in ED visits during the same period, and the likelihood of further closures due to increased hospital consolidation across the country since the study took place.

The article focuses on mortality rates and finds that hospitals in close proximity to an ED that had closed had 5 percent higher odds of inpatient mortality than admissions to hospitals not occurring near a closure, and that this effect disproportionately affected minority, Medicaid, and low-income patients, further exacerbating existing disparities in health care and health outcomes. This finding adds to Hsia’s body of work that calls attention to the disproportionate impact of institutional closures on health outcomes for vulnerable populations.

California and Emergency Services

The authors’ creative use of state-level hospital utilization data and hospital service areas (HSA) from the Dartmouth Atlas Project, (rather than using an area defined solely by proximity to a hospital), was an insightful choice that facilitated inclusion of both patient and hospital characteristics in the analysis, which allowed detection of this important phenomenon. The article appropriately draws readers to the likely conclusion that the increased mortality and decreased health equity they detected may be due to decreased access to health care services or, given the disparate impact on vulnerable populations, may be due to decreased quality due to loss of institutions with greater experience and expertise in caring for minority and disadvantaged populations.

While the Emergency Medical Treatment and Labor Act (EMTALA) mandates that all Medicare-participating hospitals that offer emergency services provide a medical screening examination when a request is made for examination or treatment for an emergency medical condition, hospitals that do not offer emergency services may be exempt. Some states, like California, do permit hospitals to close their EDs even though the hospital may remain open. Indeed, ED closure may be a prudent financial move for a hospital, since emergency departments are often the entry way for sicker, poorly insured, or uninsured patients into the institution.

Closing their ED allows a hospital to focus on more profitable services and to use financial screening procedures to exclude fiscally undesirable patients from accessing hospital services, thereby improving their payer mix. Unfortunately, as the authors demonstrate, this has a previously undocumented detrimental effect on the health of the most vulnerable patients in the surrounding community. Nearly one half (22 of 48) of the ED closures in the study fell into this category; thus it appears that California’s decision to allow hospitals to convert their ED licenses (to standby or no ED) directly contributed to the increased mortality seen in the study.

Effects on Health Outcomes

Moreover, it is possible that although ED closures may financially benefit individual hospitals, they may impose a financial burden on the system as a whole. There may be “ripple effects” on outcomes other than mortality. Perhaps delays in seeking care for non-fatal encounters actually serve to increase total health care costs. Although incentives may be changing through the advent of reimbursement reform models, such as accountable care organizations and state Medicaid health homes, the structural effect of ED closures on the surrounding communities will be long standing and difficult to reverse; the ripple effects of these closures may affect those living in these communities for years to come.

It is true that hospital closures affect direct admissions (admissions not made via the ED) differently, and it was appropriate to exclude these admissions from the primary analysis. However, it is likely that following closures of entire hospitals (slightly more than half of the closures in this study), the number of remaining inpatient beds in an area would decrease. Such a shortage of inpatient beds could cause an increase in admissions via the ED since some direct admissions may be turned away when no inpatient bed is available, forcing the acute but non-emergent patient to go to an ED while awaiting an inpatient bed. This hospital crowding results in a phenomenon called boarding (i.e. having admitted patients remain for prolonged periods in the emergency department while awaiting an inpatient bed), which is associated with worse clinical outcomes.

It would be interesting to see further analysis of this possible phenomenon in the subgroup of closures of entire hospitals. Additionally, it would also be interesting to see further investigation of the effects of ED closures on outcomes other than mortality, such as total health care costs, morbidity for non-fatal encounters, hospital length of stay, hospital readmissions, and ED visit rates.

This article begins to look at the substantial potential effects of ED closures on actual patient outcomes and adds important evidence that should spark debate among policy makers, inform decisions, and hopefully prompt further investigation.