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.