Relationship between rural hospital closures and the supply of nurse practitioners and certified registered nurse anesthetists.

BACKGROUND: Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care. PURPOSE: We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce. METHOD: Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs. FINDINGS: Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs. DISCUSSION: We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market.

Access to outpatient services in rural communities changes after hospital closure.

OBJECTIVE: Between January 2005 and July 2020, 171 rural hospitals closed across the United States. Little is known about the extent that other providers step in to fill the potential reduction in access from a rural hospital closure. The objective of this analysis is to evaluate the trends of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in rural areas prior to and following hospital closure. DATA SOURCES/STUDY SETTING: We used publicly available data from Centers for Medicare and Medicaid Provider of Services files, Cecil G. Sheps Center rural hospital closures list, and Small Area Income and Poverty Estimates. STUDY DESIGN: We described the trends over time in the number of hospitals, hospital closures, FQHC sites, and RHCs in rural and urban ZIP codes, 2006-2018. We used two-way fixed effects and pooled generalized linear models with a logit link to estimate the probabilities of having any RHC and any FQHC within 10 straight-line miles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Compared to hospitals that never closed, the predicted probability of having any FQHC within 10 miles increased post closure by 5.95 and 11.57 percentage points at 1 year and 5 years, respectively (p < 0.05). The predicted probability of having any RHC within 10 miles was not significantly different following rural hospital closure. A percentage point increase in poverty rate was associated with a 1.98 and a 1.29 percentage point increase in probabilities of having an FQHC or RHC, respectively (p < 0.001). CONCLUSIONS: In areas previously served by a rural hospital, there is a higher probability of new FQHC service-delivery sites post closure. This suggests that some of the potential reductions in access to essential preventive and diagnostic services may be filled by FQHCs. However, many rural communities may have a persistent unmet need for preventive and therapeutic care.

Deinstitutionalization and network of mental health services: a new scene in health care.

OBJECTIVE: to analyze the process of deinstitutionalization resulting from a psychiatric hospital shut down, and know the fate of users after dehospitalization. METHOD: a descriptive, qualitative study based on the critical-analytical perspective, which had as its setting the Hospital Colônia de Rio Bonito. Institutional documents and narratives of five managers who participated in the deinstitutionalization process were analyzed. RESULTS: Hospital Colônia deinstitutionalization lasted longer than expected. For this to happen, a tripartite intervention was necessary, and especially the mobilization of networks and implementation of Psychosocial Care Networks by the cities. Regarding destination of users, most were referred to therapeutic or transinstitutionalized residences. Final considerations: Hospital Colônia deinstitutionalization led to the establishment of connections between services and people. This was a powerful device for the implementation of Psychosocial Care Networks at municipal level.

When Rural Hospitals Close, The Physician Workforce Goes.

Rates of rural hospital closures have been increasing over the past decade. Closures will almost certainly restrict rural residents' access to important inpatient services, and they could also be related in important ways to the supply of physicians in the local health care system. We used data from the Area Health Resources Files for the period 1997-2016 to examine the relationship between rural hospital closures and the supply of physicians across different specialties in the years leading up to and after a closure. We observed significant annual reductions of up to 8.3 percent in the supply of general surgeons in the years leading up to a closure. We also found that rural hospital closures were associated with immediate and persistent decreases in the supply of surgical specialists and long-term decreases in the supply of physicians across multiple specialties-including an average annual 8.2 percent decrease in the supply of primary care physicians in the six years after a closure and beyond. This dynamic relationship could lead to reduced access to care for rural residents. Future policy efforts must focus on supporting and maintaining health care delivery models that do not depend on hospitals.

Evaluating the Impact of Hospital Closure on Local Emergency Department Operations.

BACKGROUND: The January 1, 2018 closure of Memorial Hospital of RI (MHRI) has anecdotally resulted in operational strain for the area's remaining EDs. This study seeks to evaluate the impact on neighboring facilities. METHODS: An interrupted time-series analysis was conducted to compare operational outcomes and demographics pre- and post-MHRI closure. Three hospitals were selected from the same health system: Miriam Hospital, Rhode Island Hospital, and Newport Hospital. RESULTS: In the first 12 months following MHRI's closure, there were significant increases in monthly ED volume, length of stay, and left without being seen rates at two area hospitals. There was also a significant diversification of the patient population at these sites. The most substantial impact was noted at Miriam Hospital, the closest remaining facility. CONCLUSION: This study demonstrates operational strain and an evolving patient population at neighboring EDs following MHRI's closure. These findings suggest the need for additional resource allocation to support clinical care and logistics.

A sociology of public responses to hospital change and closure.

The "problem" of public resistance to hospital closure is a recurring trope in health policy debates around the world. Recent papers have argued that when it comes to major change to hospitals, "the public" cannot be persuaded by clinical evidence, and that mechanisms of public involvement are ill-equipped to reconcile opposition with management desire for radical change. This paper presents data from in-depth qualitative case studies of three hospital change processes in Scotland's National Health Service, including interviews with 44 members of the public. Informed by sociological accounts of both hospitals and publics as heterogeneous, shifting entities, I explore how hospitals play meaningful roles within their communities. I identify community responses to change proposals which go beyond simple opposition, including evading, engaging with and acquiescing to changes. Explicating both hospitals and the publics they serve as complex social phenomena strengthens the case for policy and practice to prioritise dialogic processes of engagement. It also demonstrates the continuing value of careful, empirical research into public perspectives on contentious healthcare issues in the context of everyday life.

Update: Independently Owned Pharmacy Closures in Rural America, 2003-2018.

This Policy Brief continues the series of reports from the RUPRI Center updating the number of pharmacy closures in rural America with annual data. See our website for other analyses of trends and assessment of issues confronting rural pharmacies. Key Findings: (1) Over the last 16 years, 1,231 independently owned rural pharmacies (16.1 percent) in the United States have closed. The most drastic decline occurred between 2007 and 2009. This decline has continued through 2018, although at a slower rate. (2) 630 rural communities that had at least one retail (independent, chain, or franchise) pharmacy in March 2003 had no retail pharmacy in March 2018.

Psychiatric Patient Length of Stay in the Emergency Department Following Closure of a Public Psychiatric Hospital.

BACKGROUND: Psychiatric patient boarding in the emergency department (ED) is a ubiquitous problem associated with increased morbidity and mortality. OBJECTIVE: We evaluate the effect of closing a public psychiatric facility in a major metropolitan area on the ED length of stay (LOS) of psychiatric patients. METHODS: This was a retrospective chart review at two metropolitan EDs of all patients assessed to require inpatient psychiatric hospitalization. The time of arrival, time of disposition, time of transfer, insurance status, and accepting facility type were collected prior to and following the closure of a local inpatient psychiatric facility. RESULTS: We analyzed a total of 1107 patients requiring inpatient psychiatric hospitalization, with 671 patients who presented prior to the closure of the closest public psychiatric facility and 436 patients that presented following the facility closure. Following hospital closure, patients with private insurance (620 min before, 771 min after) and Medicare/Medicaid (642 min before, 718 min after) had statistically significantly longer ED LOS, as well as patients transferred to a private psychiatric hospital (664 min prior, 745 min after). However, overall ED length of stay following hospital closure for transfer of all psychiatric patients requiring inpatient hospitalization was not found to be statistically significant (1017 min prior, 967 min after). CONCLUSION: There was a statistically significant increase in ED LOS for patients with private insurance, Medicare/Medicaid, and for those patients transferred to a private psychiatric facility following closure of a public mental health hospital; however, overall, ED LOS was not increased for patients transferred to an inpatient psychiatric facility. This study highlights the significant impact that the closure of a single inpatient psychiatric facility can have on nearby EDs. We hope to bring attention to the need for increased psychiatric services during a time when there is a nationwide trend toward the reduction of available inpatient psychiatric beds.

Hospital closures and the current healthcare climate: the future of rural hospitals in the USA.

Hospital closures occur from time to time. These closures affect not only the patients that depend on the hospitals but also the economy in many rural areas. Many factors come into play when a hospital decides to shut off services. Although influencing reasons may vary, hospital closures are likely to be caused by financial shortfalls. In the USA recently, several rural hospitals have closed and many are on the verge of closing. The recent changes in the healthcare industry due to the new reforms are believed to have impacted certain small community and rural hospitals by putting them at risk of closure. In this article, we will discuss some of the highlights of the healthcare reforms and the events that followed, to relate how they may have affected the hospitals. We will also discuss what the future of these hospitals may look like and the necessary steps that the hospitals need to adopt to sustain themselves.

Trends in hospital ED closures nationwide and across Medicaid expansion, 2006-2013.

STUDY HYPOTHESIS: Low reimbursement from the uninsured has been claimed to threaten hospital finances and even hospital emergency department (ED) closure. We hypothesized in advance of beginning data collection that states that expanded Medicaid ("expansion states") under the 2010 Patient Protection and Affordable Care Act would experience a reduced rate of ED closure compared with states that did not. METHODS: We compiled a national census of EDs from 2006 through 2013 from federal databases and manually confirmed each closure. We used difference-in-differences regression on this longitudinal panel to compare the probability over time that a hospital was in operation in expansion states to nonexpansion states. RESULTS: The number of hospitals grew every year nationally and in nonexpansion states. In expansion states, the number fell from 2027 in 2009 to 2019 in 2010, not surpassing the 2009 peak until 2012. In regression estimates, hospitals in expansion states were 2.2% (95% confidence interval, 0.3%-4.1%) less likely to be in operation after 2010 compared with the trend in nonexpansion states. CONCLUSIONS: States that expanded Medicaid experienced increased, rather than reduced, ED closure rates from 2010 through 2013. The financial benefits of the Affordable Care Act may be poorly targeted to the hospitals most vulnerable to closure.

Observation Services Linked With an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster.

OBJECTIVE: The emergency department (ED) of NYU Langone Medical Center was destroyed by Hurricane Sandy, contributing to a public health disaster in New York City. We evaluated hospital-based acute care provided through the establishment of an urgent care center with an associated ED-run observation service (EDOS) that operated in the absence of an ED during this disaster. METHODS: We conducted a retrospective cohort study of all patients placed in an EDOS following a visit to an urgent care center during the 18 months of ED closure. We reviewed diagnoses, clinical protocols, selection criteria, and performance metrics. RESULTS: Of 55,723 urgent care center visits, 15,498 patients were hospitalized, and 3167 of all hospitalized patients (20.4%) were placed in the EDOS. A total of 2660 EDOS patients (84%) were discharged from the EDOS. The 8 most frequently utilized clinical protocols accounted for 76% of the EDOS volume. CONCLUSIONS: A diverse group of patients presenting to an urgent care center following the destruction of an ED by natural disaster can be cared for in an EDOS, regardless of association with a physical ED. An urgent care center with an associated EDOS can be implemented to provide patient care in a disaster situation. This may be useful when existing ED or hospital resources are compromised. (Disaster Med Public Health Preparedness. 2016;10:405-410).

The Rising Rate of Rural Hospital Closures.

PURPOSE: Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and the impact on rural communities. METHODS: The 2009 financial performance and market characteristics of rural hospitals that closed from 2010 through 2014 were compared to rural hospitals that remained open during the same period, stratified by critical access hospitals (CAHs) and other rural hospitals (ORHs). Differences were tested using Pearson's chi-square (categorical variables) and Wilcoxon rank test of medians. The relationships between negative operating margin and (1) market factors and (2) utilization/staffing factors were explored using logistic regression. FINDINGS: In 2009, CAHs that subsequently closed from 2010 through 2014 had, in general, lower levels of profitability, liquidity, equity, patient volume, and staffing. In addition, ORHs that closed had smaller market shares and operated in markets with smaller populations compared to ORHs that remained open. Odds of unprofitability were associated with both market and utilization factors. Although half of the closed hospitals ceased providing health services altogether, the remainder have since converted to an alternative health care delivery model. CONCLUSIONS: Financial and market characteristics appear to be associated with closure of rural hospitals from 2010 through 2014, suggesting that it is possible to identify hospitals at risk of closure. As closure rates show no sign of abating, it is important to study the drivers of distress in rural hospitals, as well as the potential for alternative health care delivery models.

The Relationship of Financial Pressures and Community Characteristics to Closure of Private Safety Net Clinics.

In order to better understand what threatens vulnerable populations' access to primary care, it is important to understand the factors associated with closing safety net clinics. This article examines how a clinic's financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers and nonfederally qualified health centers generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety net clinics.

The Impact of Hospital Closures and Hospital and Population Characteristics on Increasing Emergency Department Volume: A Geographic Analysis.

Emergency visits are rising nationally, whereas the number of emergency departments is shrinking. However, volume has not increased uniformly at all emergency departments. It is unclear what factors account for this variability in emergency volume growth rates. The objective of this study was to test the association of hospital and population characteristics and the effect of hospital closures with increases in emergency department volume. The study team analyzed emergency department volume at New York State hospitals from 2004 to 2010 using data from cost reports and administrative databases. Multivariate regression was used to evaluate characteristics associated with emergency volume growth. Spatial analytics and distances between hospitals were used in calculating the predicted impact of hospital closures on emergency department use. Among the 192 New York hospitals open from 2004 to 2010, the mean annual increase in emergency department visits was 2.7%, but the range was wide (-5.5% to 11.3%). Emergency volume increased nearly twice as fast at tertiary referral centers (4.8%) and nonurban hospitals (3.7% versus urban at 2.1%) after adjusting for other characteristics. The effect of hospital closures also strongly predicted variation in growth. Emergency volume is increasing faster at specific hospitals: tertiary referral centers, nonurban hospitals, and those near hospital closures. This study provides an understanding of how emergency volume varies among hospitals and predicts the effect of hospital closures in a statewide region. Understanding the impact of these factors on emergency department use is essential to ensure that these populations have access to critical emergency services.

NHS to close residential hospitals for people with learning disabilities.

Many residential hospitals for people with learning disabilities will be shut over the next two years as part of a government pledge to move people out of these settings following the Winterbourne View abuse scandal.