Associations between rural hospital closures and acute and post-acute care access and outcomes.

OBJECTIVE

To determine whether rural hospital closures affected hospital and post-acute care (PAC) use and outcomes.

STUDY SETTING AND DESIGN

Using a staggered difference-in-differences design, we evaluated associations between 32 rural hospital closures and changes in county-level: (1) travel distances to and lengths of stay at hospitals; (2) functional limitations at and time from hospital discharge to start of PAC episode; (3) 30-day readmissions and mortality and hospitalizations for a fall-related injury; and (4) population-level hospitalization and death rates.

DATA SOURCES AND ANALYTIC SAMPLE

100% Medicare claims and home health and skilled nursing facility clinical data to identify approximately 3 million discharges for older fee-for-service Medicare beneficiaries.

PRINCIPAL FINDINGS

We found that hospitals that closed compared to those remaining open served more minoritized, lower-income populations, including more Medicaid and fewer commercial patients, and had lower profit margins. Following a closure, quarterly hospitalization rates (111.6 quarterly hospitalizations per 10,000 older adults; 95% CI: 53.4, 170.9) and average hospital lengths of stay increased (0.34 days; 95% CI: 0.13, 0.56 days). We observed no change in the average distance between patients' residential ZIP code and the hospital used (0.29 miles; 95% CI: -1.06, 1.64 miles); average number of standardized ADL limitations at PAC (0.08 SDs from the pre-closure average; 95% CI: -0.12, 0.28 SDs); or PAC time to start (0.02 days; 95% CI: -1.2, 1.2 days). Among more isolated hospitals, closures were associated with an increase in the likelihood of readmission (0.10 percentage-points; 95% CI: 0.00, 0.19).

CONCLUSIONS

Closures were not associated with notably worsened health care access, function, or health, potentially because closures triggered care delivery adjustments involving increased numbers of patients seeking out higher quality care.