Gillings School of Global Public Health, University of North Carolina Chapel Hill.
University of North Carolina Chapel Hill.
Milbank Q. 2023 Sep;101(3):922-974. doi: 10.1111/1468-0009.12655. Epub 2023 May 15.
Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes.
The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care.
To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models.
We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital.
Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.
政策要点政策制定者应投资于支持农村卫生系统的计划，更有针对性地关注空间可达性和种族与族裔公平，而不仅仅是总供应或最近设施措施。医疗计划网络充足性标准应解决最近和第二近的医院护理的空间可达性问题，并纳入针对黑人和拉丁裔农村社区的公平标准。黑人和拉丁裔农村居民在获得医院护理方面存在空间不平等，这是由于农村有色人种社区中经济机会空间分配的基本结构性不平等造成的。需要长期的政策解决方案，包括赔偿，以解决这些潜在的过程。
农村医院关闭率的上升引起了人们对医院为基础的护理可及性下降的担忧。我们的研究目标如下：1）描述 2007 年至 2018 年美国南部农村医院供应的变化，包括卫生系统关闭、合并和转换；2）量化人口最容易受到医院关闭后不良后果影响的农村社区（黑人和拉丁裔农村社区）的空间可达性；3）使用多层次模型检验结构因素与护理空间可达性差距之间的关系。
为了计算空间可达性，我们估计了 2007 年和 2018 年人口加权质心到最近和第二近运营医院的网络旅行距离和时间。此后，为了描述与 2018 年医院为基础的护理空间可达性相关的地方的人口统计和卫生系统特征，我们估计了三级（普查区、县、州级）广义线性模型。
我们发现，2007 年至 2018 年间，南部 72 个（10%）农村县至少有一家医院关闭，近一半（33 家）的关闭县失去了最后一家仍在运营的医院。扣除关闭、合并和转换的影响，医院的供应从 783 家下降到 653 家。总体而言，49.1%的农村地区最近的医院空间可达性恶化，而较小比例的地区在 2007 年至 2018 年间的可达性得到改善（32.4%）或保持不变（18.5%）。与非关闭县相比，位于关闭县的普查区前往最近的急症护理医院的旅行时间更长。此外，南部各州商业医疗保险市场集中程度较高的农村地区，前往第二近的开放急症护理医院的旅行时间更短。
受农村医院关闭影响的农村地区，急症护理的出行负担更大。在整个南部农村地区，当考虑到第二近的开放急症护理医院的出行时间时，在获得急症护理的空间公平性方面，种族/族裔的不平等最为明显。
