Department of Emergency Medicine, University of California, San Francisco, CA, USA.
JAMA. 2011 May 18;305(19):1978-85. doi: 10.1001/jama.2011.620.
Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient's ability to pay may make EDs more vulnerable to the market forces that govern US health care.
To determine hospital, community, and market factors associated with ED closures.
Emergency department and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84%-92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety net [as defined by hospitals caring for more than double their Medicaid share of discharges compared with other hospitals within a 15-mile radius], ownership, teaching status, system membership, ED size, case mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs).
All general, acute, nonrural, short-stay hospitals in the United States with an operating ED anytime from 1990-2009.
Closure of an ED during the study period.
From 1990 to 2009, the number of hospitals with EDs in nonrural areas declined from 2446 to 1779, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2814 urban acute-care hospitals, constituting 36,335 hospital-year observations over an 18-year study interval (1990-2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (cumulative hazard rate based on bivariate model, 26% vs 16%; hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1, and 36% vs 18%; HR, 1.9; 95% CI, 1.6-2.3, respectively). Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR, 1.3; 95% CI, 1.1-1.6), as did safety-net hospitals (10% vs 6%; HR, 1.4; 95% CI, 1.1-1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR, 1.4; 95% CI, 1.1-1.7).
From 1990 to 2009, the number of hospital EDs in nonrural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure.
1998 年至 2008 年间，美国的医院急诊部数量有所减少，而急诊就诊人数却有所增加，尤其是那些有公共保险和无保险的患者。关于与急诊部关闭相关的医院、社区和市场因素知之甚少。要求急诊部为所有有需要的人提供治疗，无论患者的支付能力如何，这一联邦法律可能会使急诊部更容易受到美国医疗保健市场力量的影响。
确定与急诊部关闭相关的医院、社区和市场因素。
1990 年至 2009 年的急诊部和医院组织信息来自美国医院协会（AHA）年度调查（年度响应率在 84%-92%之间），并与 2007 年通过医疗保险医院成本报告获得的医院财务和支付者组合信息合并。我们评估了三组风险因素：医院特征（安全网[定义为为比其所在 15 英里半径内的其他医院多两倍以上的 Medicaid 出院患者提供护理的医院]、所有权、教学地位、系统成员、ED 规模、病例组合）、县人口统计学特征（种族、贫困、无保险、老年人）和市场因素（所有权组合、利润率、在竞争市场中的位置、其他 ED 的存在）。
1990 年至 2009 年间，美国所有拥有运营 ED 的普通、急性、非农村、短期住院医院。
研究期间 ED 的关闭情况。
1990 年至 2009 年，非农村地区拥有 ED 的医院数量从 2446 家减少到 1779 家，有 1041 家 ED 关闭，374 家医院开设 ED。在对 2814 家城市急性护理医院进行分析后，在 18 年的研究期间（1990-2007 年），构成了 36335 个医院年观察值，发现营利性医院和利润率较低的医院更有可能关闭（基于双变量模型的累积风险率，26%比 16%；风险比[HR]，1.8；95%置信区间[CI]，1.5-2.1，和 36%比 18%；HR，1.9；95% CI，1.6-2.3）。竞争激烈的市场中的医院关闭的风险显著增加（34%比 17%；HR，1.3；95% CI，1.1-1.6），安全网医院也是如此（10%比 6%；HR，1.4；95% CI，1.1-1.7）和为更多贫困人群提供服务的医院（37%比 31%；HR，1.4；95% CI，1.1-1.7）。
1990 年至 2009 年间，非农村地区医院急诊部数量减少了 27%，营利性所有权、竞争市场位置、安全网地位和低利润率与急诊部关闭风险增加相关。
