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Rural Health System Resources


Evidence Brief: Effects of Small Hospital Closure on Patient Health Outcomes


Carson S, Peterson K, Humphrey L, Helfand M.


The United States Veterans Health Administration (VHA) developed evidence brief evaluating the size thresholds needed for small general medical/surgical hospitals to maintain safe and high-quality care by comparing small hospitals with larger ones. The evidence brief found that closing small hospitals in rural areas can increase travel time to the nearest facility, while patients in urban areas are less likely to experience increases in travel time after an urban hospital closure A recent study conducted simulations of closures of nine Japanese hospitals serving patients requiring hemodialysis. Five rural public hospitals and four urban public hospitals were chosen for the model. The model simulated the closure of each rural hospital, each urban hospital, all rural hospitals, all urban hospitals, and shifting capacity of the urban hospitals to the rural hospitals. Simulation results showed that if public hospitals in rural areas were closed, the equity of commuting times among patients worsened much more than if urban public hospitals of similar capacity were closed. Closing of even the smallest rural facility (total capacity 15) affected equity of commuting times more than closure of the large urban hospitals. In a study of hospital emergency department closures in California, including 785,385 patient records, only a small proportion of patients (10% of the sample) experienced an increase in distance to the nearest emergency department as a result of a urban hospital closure, and among them, most had less than a one-mile increase. Another U.S. study looked at the effect of increased driving time to the nearest emergency department over a 10-year period (1995-2005). Patients who experienced the largest increases in driving time were mostly in rural communities. These patients also had more limited access to other hospitals, with the average number of hospitals within a 10-mile radius only 1.03 compared to 2.57 in the control group.

Why is this useful for rural and remote people?

This article is important part of the advocacy toolkit for rural and remote communities in arguing for investment in local health and hospital capacity. One of the factors that is often overlooked in the decision to close a rural or remote health service, or to withdraw key services (e.g. dialysis), is the impact that these health system decisions have on travel time for rural and remote people to access those same services in a centralised city hospital or health service. This study is unique in comparing the impact on urban and rural populations of hospital closures. The idea of closing an urban hospital is rarely contemplated by governments when looking for savings in heath system because this would be electorally unpopular. However when an equity or social justice lens is applied, the impact of closing a rural hospital compared to an urban hospital is significantly greater. In urban areas there are a large number of hospitals in relatively short distances from each other, but in rural areas hospitals can sometimes be 100-500km apart. The closure of a rural hospital leads to increased travel time for patients, greater safety risks for sick people (the majority of road deaths in Australia occur on rural and remote roads) and higher costs for rural people (who are typically the most socioeconomically disadvantaged groups in Australia). By comparison, the study suggests that consolidating two or more urban hospitals on one site would have a marginal impact on travel time and cost for people in cities, but would not incur the same health and safety risks for patients as closing a rural hospital. It is arguable that consolidating and centralising two or more urban hospital services would lead to more significantly greater cost-efficiencies compared to closing small rural hospitals and health services, without impacting the health of people in major cities.

Suggested Citation

Carson S, Peterson K, Humphrey L, Helfand M. Evidence Brief: Effects of Small Hospital Closure on Patient Health Outcomes [Internet]. Washington (DC): Department of Veterans Affairs (US); 2013 Jun. PMID: 27606393.


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