Fewer Emergency Rooms Available As Need Arises

New York Times | Hospital emergency rooms, particularly those serving the urban poor, are closing at an alarming rate even as emergency visits are rising, according to a report published on Tuesday.

Urban and suburban areas have lost a quarter of their hospital emergency departments over the last 20 years, according to the study, in The Journal of the American Medical Association. In 1990, there were 2,446 hospitalswith emergency departments in nonrural areas. That number dropped to 1,779 in 2009, even as the total number of emergency room visits nationwide increased by roughly 35 percent.

Emergency departments were most likely to have closed if they served large numbers of the poor, were at commercially operated hospitals, were in hospitals with skimpy profit margins or operated in highly competitive markets, the researchers found.

Although the study did not examine emergency care at the remaining facilities, the closings take a toll on the quality of care in all emergency rooms, said Dr. Renee Y. Hsia, an assistant professor of emergency medicine at the University of California, San Francisco, and the lead author of the study.

“Some people think, ‘As long as my emergency room isn’t closing, I feel O.K. and protected,’ ” said Dr. Hsia, whose research was financed by the Robert Wood Johnson Foundation. “But even if they don’t lose the E.R. in their own neighborhood, they do experience the effect of fewer emergency rooms — the waits get longer and longer, and people’s outcomes get worse.”

New York City lost three hospital emergency rooms in 2008, two in 2009 and two more last year, when St. Vincent’s Hospital Manhattan in Greenwich Village closed, followed by North General Hospital in Harlem. St. Vincent’s had handled more than 60,000 emergency visits a year, while North General’s E.R. had recorded 36,000 annual visits.

A 24-hour emergency care and ambulatory surgery center, operated by North Shore-Long Island Jewish Health System, is planned for Greenwich Village. Neighborhood advocates have expressed concern that the free-standing emergency room will not be able to deliver adequate care without the backing of a full-service acute-care hospital.

The new study warns of delays in emergency care that are already playing out in the community, said Dr. David L. Kaufman, a member of the Coalition for a New Village Hospital who worked at St. Vincent’s for more than 30 years. Patients who would have sought care at St. Vincent’s, he said, “take longer to get to nearby hospitals in New York City traffic. They’re waiting many, many hours to be seen and managed, and if they require admission, they have to wait another 12 to 24 hours because there are no beds.”

The aim of the analysis was to figure out what characteristics make a hospital emergency department likely to close, Dr. Hsia said. Rural hospitals were excluded because some are designated “critical access hospitals” and operate under federal mandate.

Emergency rooms at commercially operated hospitals and those with low profit margins were almost twice as likely as other hospitals to close, Dr. Hsia and her colleagues found. So-called safety-net hospitals that serve disproportionate numbers of Medicaid patients and hospitals serving a large share of the poor were 40 percent more likely to close.

In addition, hospital emergency rooms in the most competitive markets were 30 percent more likely than others to close.

“This suggests market forces play a larger role in the distribution and availability of care” in the United States, Dr. Hsia said, especially emergency care. “We can’t expect the market to allocate critical resources like these in an equitable way.”

Conditions in emergency rooms may be worsened by the new health care law, several experts said. The law will expand eligibility for Medicaid, the government health plan for the poor. Often beneficiaries turn to emergency rooms for care, because many physicians do not accept Medicaid payments, said Dr. Sandra M. Schneider, president of the American College of Emergency Physicians.

Emergency rooms are required by law to provide treatment regardless of ability to pay. “People will have coverage, but there’s a concern that there will be nowhere for them to go,” Dr. Schneider said.

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