In the last 20 years, the number of U.S. hospital emergency departments in nonrural areas has declined by nearly 30 percent, according to a recent study in the Journal of the American Medical Association. To determine the forces behind these closures, researchers used three sets of risk factors to analyze 2,814 urban acute care hospitals:

  • Hospital characteristics (safety net, ownership, teaching status, system membership, ED size, case mix)
  • County population demographics (race, poverty, lack of insurance, age)
  • Market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs).

From 1990 to 2009, the number of hospitals with EDs in nonrural areas decreased from 2,446 to 1,779. From 1990 to 2007, EDs that closed were more likely to be at for-profit hospitals than EDs that remained open (26 percent vs. 16 percent). Smaller facilities were more likely to close their EDs; and twice as many hospitals that clos-ed their EDs were in the lowest quartile of profit margin distribution, compared with those that kept EDs open.

EDs that closed tended to be located in counties with high shares of minority populations (36 percent vs. 31 percent), high shares of populations in poverty (37 percent vs. 31 percent), and more than 15 percent of uninsured (42 percent vs. 36 percent). Thirty-four percent of EDs that closed were in highly competitive markets, compared with 17 percent of those with EDs that did not close.

Adjusted analysis indicated that three hospital-specific characteristics were associated with an increased risk of ED closures: safety-net status, for-profit status, and hospitals with profit margins in the lowest quartile. And after fully adjusting for all factors in the model, EDs in communities with the highest percentage of poverty were at increased risk of closure. Also, presence of another ED within a 15-mile radius and hospitals in areas with high levels of competition were at higher risk of closure. Note, however, that the study did not look at rural areas nor factor in market consolidation.