EMS Response Times When a Hospital Closes - PowerPoint Presentation

1. EMS Response Times When a Hospital ClosesSuZanne Troske; Sookti Chaudhary; Kenneth Troske; Alison DavisNovember 12, 2018

2. Research QuestionWhen a hospital closes in a community what are the short-run changes in ambulance response times?Do patients spend more time in an ambulance being transported to an emergency department?What is the importance to patients and communities?

3. Distance and Time to EDIs there a change in distance and time to an ED when a hospital closes?Closed hospitals in rural areas average 13 miles away from the next closest hospital. (Kaufman et al. 2016)In California, 8.6% of patients had increased distance to ED in urban areas (0.1 to 33.4 miles). (Hsia et al. 2012)

4. Patient ChoiceDo patients make different choices when closest ED closes?Los Angeles County study found a shift away from EDs to primary care physicians. (Buchmueller et al. 2006)Fewer than predicted patients going to next closest ED in New York. (Lee et al. 2015) Affects number of transports and not time.

5. Ambulance ServiceDoes the ambulance service change?Level of service could change if it is hospital-based.In the short-run, we assume ambulance services do not move and offer the same level of care as prior to the closure. In communities with few vehicles or vehicles in high demand, response times could change as they travel further to next ED.

6. Patient Health OutcomesWhat are the effects on health outcomes of increased distance or time to an ED?Blanchard et al. (2011), Detsky et al. (1996), Blackwell et al. (2009): Find little effect of response times on patient outcomesWilde (2013): Strong significant impact of response times on mortalityJena et al. (2017): Change in mortality of Medicare-aged patients suffering from heart attack Response time during a marathonPatients delayed by 4.4 minutes (32% longer trip)Five week mortality rate increased by 5% points

7. Hospital ClosuresHospital data:List of urban and rural hospital closures Years 2011-2014, 91 hospitals closed, half in rural areas. In most cases, ED services also closedList of all Medicare-approved hospitals by location by yearFinal hospital file:Zip code level file with number of hospitals with hospital and zip code characteristics and indicator for a closed hospital by year.

8. Hospital Closures 2011-2014Red = RuralBlue = UrbanOne closure in HI (not shown)

9. Data are from NEMSIS (National Emergency Medical Services Information System)Years 2010 to 2015 9-1-1 emergency calls transported by EMS to ED by ground transportDe-identified incident statistics on a single ambulance usePatient, ambulance service and incident location characteristicsLimitations of data:NEMSIS is a convenience sample meaning the data are voluntarily collected from states.In 2015, 47 states and DC reported data. DE, MA, OH and TX do not report.Ambulance Service

10. Emergency 911 CallScene TimeTransport TimeTotal Response TimeTime to SceneAmbulance Call Times

11. MethodologyUsing hospital data, we construct “treated” and “comparison” groups of zip codes which look similar using propensity score matching.Zip codes are matched to the ambulance call data for one year prior and one year after the year of hospital closure.

12. Difference-in-Difference ModelDifference-in-Difference estimation controlling for patient, ambulance service and location characteristics. Difference-in-difference (DD) estimator:δ = (TTy2,hc=1,pc=1 -TTy2,hc=0,pc=1) – (TTy1,hc=1,pc=0 -TTy1,hc=0,pc=0)Year 1Year before closure Year 2 Year after closureComparison Zip with No Hospital closureTT hospclose = 0 postclose = 0TT hospclose = 0postclose = 1Treated Zip where Hospital closedTT hospclose = 1 postclose = 0TT hospclose = 1postclose = 1

13. Transport Time in an ambulance after hospital closureIndependent variablesTotalTotal with controlsRural with controlsConstant11.21***14.00***14.09***(0.037)(0.123)(0.175)postclose*hospclose2.23***2.36***13.40***(0.119)(0.117)(0.290)postclose-0.10***0.09***0.25***(0.012)(0.006)(0.016)hospclose2.03***1.61***1.33***(0.091)(0.092)(0.229)Other controlsNoYesYesObservations15,024,81114,595,5502,786,975R-squared0.00050.02470.0265Clustered standard errors for the destination day of the week and hour of the day.

14. Time to scene and Scene time after rural closureTime to SceneScene TimeConstant8.49***10.54***(0.069)(0.055)postclose*hospclose-0.25*1.94***(0.131)(0.184)postclose0.59***-0.07***(0.007)(0.008)hospclose-0.25***-0.43***(0.096)(0.124)Other controlsYesYesObservations2,785,4892,785,561R-squared0.03070.0316Clustered standard errors for the destination day of the week and hour of the day.

15. ConclusionsIn the short-run when a hospital closes rural patients spend an additional 13 minutes in an ambulance almost doubling their time.And spend more time than urban patients facing closures.National Advisory Committee on Rural Health and Human Services in a 2016 policy brief emphasized need for ambulance services when discussing preserving access to emergency care in rural areas.Future work we want to look at number of patients and ambulance calls and patient outcomes.

16. QuestionsRural and Underserved Health Research Centerhttps://ruhrc.uky.edu/Community and Economic Development Initiative of Kentuckyhttps://cedik.ca.uky.edu/The Rural & Underserved Health Research Center is supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement # U1CRH30041. The information, conclusions and opinions expressed in this presentation are those of the authors and no endorsement by FORHP, HRSA, HHS, or the University of Kentucky is intended or should be inferred.