...933 out of 2,814 urban acute-care hospitals (33%) shut their emergency departments or closed altogether...

Hospital emergency departments in the U.S. are becoming scarcer even as the number of patient visits is increasing, and economic factors appear to be a major factor in the loss of these services, researchers said.

From 1990 to 2007, 933 out of 2,814 urban acute-care hospitals (33%) shut their emergency departments or closed altogether, according to Renee Hsia, MD, of the University of California San Francisco, and colleagues.

Those shutting down were more likely to have been for-profit or in for-profit facilities, in competitive markets, and with low profit margins, Hsia and colleagues reported in the May 18 issue of the Journal of the American Medical Association.

"Safety-net" designation was also a significant factor, even after controlling for demographic and market factors.

This finding, Hsia and colleagues wrote, "signals that safety-net hospitals may require particular attention if emergency care access is to be sustained."

The reduction in emergency departments has become a worrisome trend as population growth and problems with access to primary care have driven up patient visits.

To get a better picture of the situation, Hsia and colleagues obtained data on 2,814 urban acute-care hospitals from the American Hospital Association (AHA) and Medicare, covering case mix, ownership, teaching status, location relative to other emergency rooms, service area demographics, and financial performance.

The researchers found that the following factors were significantly associated with the likelihood of emergency department closure:

For-profit status: hazard ratio 1.8 (95% CI 1.5 to 2.1)
Low profit margin: HR 1.9 (95% CI 1.6 to 2.3)
Competitive market: HR 1.3, 95% CI 1.1 to 1.6)
Safety-net status: HR 1.4 (95% CI 1.1 to 1.7)
Serving higher share of populations in poverty: HR 1.4 (95% CI 1.1 to 1.7)

Hsia and colleagues measured competitive status with the Herfindahl index, which measures market share according to the number of patient discharges. When it was defined more simply as the presence or absence of another emergency department within 15 miles, it became a more powerful risk factor for closure (HR 1.8, 95% CI 1.3 to 2.5).

The researchers conceded that an emergency department closure "may be of little consequence" in competitive markets, since by definition another facility is available to patients needing emergency care.

"Some might assert that such 'creative destruction' is a manifestation of a healthy marketplace," they wrote.

But they dismissed that argument, pointing out the large number of people without health insurance or with public insurance that does not reimburse institutions' full costs.

Hsia and colleagues also argued that emergency department closures can't help but make care less accessible for some patients, both by increasing the distance they must travel and by increasing loads and wait times at the remaining facilities.

"Our findings underscore that market-based approaches to healthcare do not ensure that care will be equitably distributed. In fact, the opposite may be true," they concluded.

The researchers acknowledged several limitations to the analysis: Not all factors that might affect emergency department operations were measured in the available data; Veterans Affairs and other federal hospitals were excluded; and the study period ended before the current economic recession.

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Monster Rain wrote:I wish I could read the tone in which something is intended.

I can't tell if you're being complimentary or not.