Closing a rural hospital can have a multi-faceted impact on a community’s health. It can reduce care access, disrupt care patterns, and limit the range of services available. We chose to focus this analysis on whether closure reduces local Emergency Department (ED) utilization because the impact can be tested using Medicare hospital claims. We expected to see a drop in utilization if local patients had less access to emergency care after hospital closure.

The main takeaway: We found no clear relationship between hospital closure and sustained ED volume loss for counties where closure occurred. But health system and community leaders still need to create a comprehensive transition plan to maintain patients’ access to care.

Here’s what we did.

We identified counties where a rural hospital closed in either 2017 or 2018. For these 21 counties, we observed how Medicare Fee-for-Service (FFS) ED volumes changed in the two years after
closure.^{1, 2}

To account for changes in the Medicare population, we converted these ED volumes to use rates. For example 5,000 ED volumes in a county of 10,000 Medicare enrollees would give us an ED use rate of 0.5.

Three findings from our analysis

1. ED use rates decline after closure…

In the year following closure, 15 out of the 21 counties saw their ED use rates decline. Across these 21 counties, the one-year decline in rates of ED use was 5% at the median.

In counties where we have visibility into the second year after closure, the decline is even more pronounced. Across these 10 counties, the two-year decline in rates of ED use was 12% at the median.

At first glance, this graph tells a compelling story: the hospital closes and ED use declines. But declines in ED use might have occurred for other reasons.

2. …but that’s probably due to wider trends in ED utilization

We looked at ED utilization across all other rural counties to test whether the decline could be the result of a larger trend instead of closure.

That analysis showed that ED utilization declined at a similar rate across other rural markets too, regardless of whether the county experience hospital closure. Because we’re looking at changes in ED use rates rather than number of cases, this decline can’t be attributed to a shrinking Medicare population living in those communities where a hospital closed.

If hospital closure does reduce a community’s access to ED care, we’d see each county’s ED use rates decline relative to the other rural counties in the hospital’s region. Yet when we compared ED use rate trends between each county and their rural region, the split was barely more than a coin flip: six of the 10 counties experienced an outsized decline in ED utilization relative to the other rural counties in each hospital’s region.

3. No strong relationship between alternative care options and ED use trends

We wanted to know why some counties experienced outsized declines in ED use while others did not. One variable we tested in the data was differences in access to alternative care sites because patients with reduced access might instead forego care altogether. This could happen if a patient needs to travel further to reach the next closest ED or identify an alternative ED care site, such as an urgent care facility. We expected that closure would have a smaller impact on counties with alternative care options.

To test this theory, we measured two variables in the data: presence of alternative ED services within county lines and whether the hospital converted to offering other health services instead of closing completely. ⁴

This theory didn’t bear out in the data either—we found no relationship between presence of alternative ED services or hospital conversion type on ED use in the two years following hospital closure (p-value of 0.3 and 0.9 respectively.)

Parting thoughts

In this analysis we didn’t observe a clear impact of rural hospital closure on access to emergency care.

But it also raises additional questions. First, our findings don’t suggest that health system and community leaders can neglect transition planning to ensure patients have continued access to care.

There may not have been a clear effect in our analysis because hospital and community leaders effectively planned for emergency options following closure, which mitigated the impact on emergency utilization for some counties.

We focused on emergency utilization because we expected to see an outsized impact on volumes for that type of care. But we didn’t investigate the impact on outcomes—let alone how closure might affect utilization of non-emergency services.

Finally, this approach leaves open the question of whether closure impacts appropriate and inappropriate ED utilization differently. If a community maintains access to preventive services, hospital closure could cause a favorable decline in inappropriate ED utilization as low-acuity patients are directed to the right care site for their needs.

If you’ve explored these questions—or have others we should be thinking about, help guide our research by reaching out to Phoebe Donovan at DonovanP@advisory.com.

Footnotes

¹ One county experienced two rural hospital closures in the same month and year. This county is only counted once in the analysis.
² ED claims defined as inpatient and outpatient claims with services tagged to an emergency room revenue center code.
³ Comparison market defined as all other rural counties located in the same National Center for Chronic Disease Prevention and Health Promotion region as defined by the CDC. Comparison market excludes counties that experienced rural hospital closure between 2016 to 2019. County considered rural if it does not include an urban tract or is considered a micropolitan statistical area.
⁴ Alternative ED services include ED and urgent care centers. Hospital is considered converted if the facility still provides primary, outpatient, rural health, urgent or emergency care.

Sources

“Delineation Files,” United State Census Bureau.
“National Center for Chronic Disease Prevention and Health Promotion Regions,” Centers for Disease Control and Prevention (CDC).
“Rural-Urban Commuting Area Codes,” Economic Research Service, U.S. Department of Agriculture.
“Rural Hospital Closures,” The Cecil G. Sheps Center for Health Services Research.