Emergency department closures can be lethal

Geographical Distribution of Emergency Department Closures and Consequences on Heart Attack Patients

By Yu-Chu Shen Renee Y. Hsia
National Bureau of Economic Research, November 2016

NBER Working Paper 22861


We develop a conceptual framework and empirically investigate how a permanent emergency department (ED) closure affects patients with acute myocardial infarction (AMI). We first document that large increases in driving time to closest ED are more likely to happen in low- income communities and communities that had fewer medical resources at baseline. Then using a difference-in-differences design, we estimate the effect of an ED closure on access to cardiac care technology, treatment, and health outcomes among Medicare patients with AMI who lived in 24,567 ZIP codes that experienced no change, an increase of <10 minutes, 10 to <30 minutes, and 30 minutes in driving time to their closest ED. Overall, access to cardiac care declined in all communities experiencing a closure, with access to a coronary care unit decreasing by 18.64 percentage points (95% CI -30.15, -7.12) for those experiencing 30-minute increase in driving time. Even after controlling for access to technology and treatment, patients with the longest delays experienced a 6.58 (95% CI 2.49, 10.68) and 6.52 (95%CI 1.69, 11.35) percentage point increase in 90-day and 1-year mortality, respectively, compared with those not experiencing changes in distance. Our results also suggest that the predominant mechanism behind the mortality increase appeared to be time delay as opposed to availability of specialized cardiac treatment.

From the Discussion

Our results suggested that when patients had to drive at least 10 more minutes to their next available ED upon local ED closure, time delay became the dominant mechanism in affecting health outcomes when local ED closure occurred, both directly (as time delays causes more severe infarction) and indirectly through its effect on access and treatment.

The adverse effect of time delay on mortality rates became evident in communities that experienced 10-30 min increase in driving time, and became substantial in communities that experienced more than 30-minute increase in driving time. The adverse effect did not resolve even after we controlled for access and treatment, suggesting that the time delays likely made the prognosis worse, directly affecting mortality rates.


Our study showed that patients with AMI whose driving time to the nearest ED after local ED closure increased by 10 minutes or more had a significant increase in mortality. Among those who experienced a closure that resulted in a drive time increase of 30 minutes or more, they experienced a 30% higher 90-day mortality and 21% higher 1-year mortality. Increased driving time due to a closure was also associated with an overall decrease in access to cardiac technology in the remaining hospitals. Our findings suggest that permanent ED closure has substantial consequences on patient outcomes, particularly among communities with limited resources for time-sensitive illnesses such as AMI. We find that the predominant mechanism by which patients’ outcomes decline is primarily due to time delay, as opposed to changes in availability of treatment. We can conclude that while provision of necessary cardiac technology is one important factor for remaining hospitals, the effects of a time delay due to an ED closure are not easily mitigated.



By Don McCanne, M.D.

Under our medical-industrial complex, decisions regarding location of facilities such as emergency departments are frequently based on business considerations of the market rather than on what would be optimal for the community. This NBER paper demonstrates that such decisions can be a matter of life or death. If closure of an emergency department results in more than a ten minute delay in access to the next closest hospital, mortality for an acute myocardial infarction is increased.

Under a well designed single payer system, planning is an integral part and is based on community need rather than on private profit potential. This is today’s message. What follows is a personal anecdote which you can skip unless you are curious.

Our community hospital in San Clemente, California - Saddleback Memorial Medical Center - is part of the MemorialCare Health System, located in Los Angeles and Orange Counties. It was decided that the San Clemente campus be converted from an acute care hospital into an outpatient center. After months of controversy and the inability to agree on this change, the owners decided to close our hospital, including the emergency department. It is now surrounded by a chain-link fence.

According to Google, the additional time required to travel to Mission Hospital in Mission Viejo is 13 minutes, longer than the ten minute delay than can increase mortality in the event of an acute myocardial infarction, according to this study. But our freeway is frequently heavily congested due to stop-and-go beach traffic, especially throughout the extended weekend. The alternate route over surface roads is 23 minutes, according to Google. People will die.

One tiny glimmer of hope is that the hospital has refused to release the portraits of the former chiefs of staff hanging in a hallway (mine included). This suggests that the hospital owners have not given up on the facility. However it is likely that they will continue their demand that it be converted to an outpatient facility.

Why would they do this? An outpatient facility can be used to feed lucrative elective cases to their larger facility - Saddleback Memorial Medical Center in Laguna Hills - whereas, as the only hospital in San Clemente, by virtue of EMTALA they would have to take all cases regardless of insurance status and profitability.

Even though MemorialCare is non-profit, it is still very much an active part of the medical-industrial complex. Although the delivery system can remain private, non-profit, we really do need a universal public financing system - a single payer improved Medicare for all. And we want our hospital back.