Do Hospital Closures Affect Patient Time in an Ambulance?


When a hospital closes in a community, patients needing emergency care may spend more time in an ambulance to receive care in an emergency department (ED). We explored how a hospital closure affects the time a patient travels from an incident location where 9-1-1 was called to the ED in an ambulance.

By combining several data sources, we created a file summarizing hospitals and hospital characteristics at the ZIP code level. Our data had 91 closures in the years 2011 to 2014, divided evenly among rural and urban areas. The closed rural hospitals were smaller, averaging just 39 beds as opposed to 108 beds for all closed hospitals. Most hospitals, closed and open, were the sole hospital in the ZIP code. To assemble a file with the total time a patient is transported in an ambulance from the scene of an incident to the ED, we used data from the National Emergency Medical Services Information System (NEMSIS), a national repository of ambulance call data reporting total transports (not number of patients). Based on information about which jurisdictions reported to NEMSIS, we estimated there were 46 hospital closures that we could match to NEMSIS. This sample set of hospitals looked similar to all closed hospitals. We evaluated differences in transport times in a ZIP code broken out by the following characteristics: all calls, all calls without hospital-based ambulance services, calls in rural ZIP codes, calls in urban ZIP codes, rural calls without hospital-based ambulance services, and rural calls for patients 65 years and older.

For those calls defined as rural, the mean transport time prior to a hospital closure was 14.2 minutes, one minute slower than the mean time for all calls. The transport time increased to 25.1 minutes after the hospital closed, a statistically significant increase of 10.9 minutes or a 76.4% increase. In urban ZIP codes there was no change in transport times. Patients 65 years and older living in rural areas had a similar change in transport time as all rural patients. The times increased from 13.9 minutes to 27.6 minutes, a 13.7-minute increase or a 97.9% change.

Our work measures one aspect of how access to emergency care through ambulance services changes for patients when a hospital closes. Our analysis reveals that after a hospital closes, rural patients spend more time in an ambulance than prior to the closure. In addition, they spend more time than urban patients facing closures. Studies have found that communities, rural and urban, where hospitals closed tended to have a higher percentage of elderly and poor residents in addition to higher unemployment rates and a higher percentage of blacks and Hispanics. More than half the hospitals in the country are in rural areas and are the primary source of emergency medical services in these communities. Over the years, policymakers at the local, state, and federal levels have prioritized maintaining local access to emergency services. The 2017 Medicare Payment Advisory Commission (MedPAC) report stressed the need to find more efficient and financially stable ways to deliver emergency services in rural communities.

Rural and Underserved Health Research Center
SuZanne Troske, Alison Davis