Fewer emergency rooms raises concern

By Dr. Ananya Mandal, MDMay 17 2011

According to a report released Tuesday this week, the number of emergency rooms has dropped by more than a quarter over the past two decades, while patient visits have kept rising. This has resulted in overcrowded ERs that can't provide optimal care for their patients, according to the new findings, published in the Journal of the American Medical Association.

Dr. Renee Hsia, an emergency physician at the University of California, San Francisco, who worked on the study said, “This is a continuously deteriorating situation… It's a threat to everyone's care.” This the first study of its kind. Hsia and her colleagues used data from the American Hospital Association to track which hospitals closed or opened ERs across the nation.

Hsia says she and colleagues did a “survival analysis,” much like researchers do for breast cancer patients. “In our study, we used the ER as the patient,” says Hsia. They found that the number of emergency departments dropped from 2,446 to 1,779 - an average of 89 closings per year. The figure included only non-rural locations since those in rural areas generally receive special funding from federal sources. “That's a huge number,” Hsia said. She added, “When you look at ER visits over the same time period, there was a 35-per cent increase.”

Experts say that ERs are the only part of the U.S. healthcare system required to treat all patients, regardless of whether they can pay. But hospitals aren't required to have an ER, Hsia said, so that is a natural place to look for savings when the economy is tight.

Linking the ER closures to individual hospitals' financial information and their patient mix, the researchers found that several factors were tied to ER closure. The explained that for-profit hospitals were more like to shut down their ERs, compared to non-profit and government hospitals. The data showed that 26 per cent of the closed ERs were at for-profit hospitals, compared to only 16 per cent of those than stayed open. Hospitals that closed their ERs were also more likely to have low profit margins. ERs that were shut down also tended to be located in highly competitive markets and serve a higher proportion of poor people.

“This shows that the market forces very much are at play in our healthcare system,” said Hsia. “My opinion is that when we rely on a market-based approach, we can't expect resources to be distributed in an equitable fashion.”

With a rising demand and a diminishing supply, the remaining ERs become increasingly crowded, producing nationwide repercussions. “There are very good studies to show that crowding definitely does affect how well people do…When we leave things up to the market these are the effects that we see,” she said. Hsia said the situation is approaching an emergency and needs strong policy changes.

It's a myth that ERs are sucking the healthcare system dry, says Sandra Schneider, president of the American College of Emergency Physicians. “About 92% of patients who come to ERs have to be there. So you're not going to get the money you need by closing emergency departments,” Schneider says. She says studies show only 2% of total healthcare costs occur in emergency medicine, while treating obesity-related illnesses is linked to about 20% of costs, and hospital readmission rates are linked to about 15%. “The ER is the bird's eye perspective of the whole healthcare system. If we really want a better system, not just band-aid solutions, we need to look at how to simplify the way we pay for health care,” says Hsia.