Urban hospital closures and relocations have resulted in care that is of "better technical quality," but the surviving institutions are less accessible and have higher costs, a new analysis concludes.
Those findings raise troubling public health and economic questions about the effects of hospital reconfigurations in urban America. They are worries that Alan Sager, a professor at Boston University's School of Public Health, has been writing about since the early 1980s.
"We worry that even if overall savings are achieved through reconfiguration, this will be through denying care to patients in need," Sager and fellow researcher Deborah Socolar concluded. "We are skeptical that savings are being won by shifting inpatient care to more efficient hospitals or by moving care from hospitals to more efficient sites outside the hospital."
Sager and Socolar presented their report at the American Public Health Association's annual meeting in New York last week. The findings represent the first six months of a two-year investigation into hospital closings and relocations that they are conducting under a Robert Wood Johnson Foundation grant.
In the 52 large and mid-size cities studied, some 447 hospitals closed, 135 relocated and 451 were built between 1936 and 1995. Of the 721 hospitals that were open in 1936, the earliest year for which complete data were available, 57% had closed or relocated by 1995.
By comparing hospitals that closed or relocated between 1980 and 1995 with surviving institutions, Sager and Socolar identified five factors that "significantly predicted survival." Those included having more admissions, fewer minorities within the hospital's neighborhood, tighter medical school affiliations, a higher occupancy rate and fewer competing hospitals within a mile.
Between 1990 and 1995, three of the factors-admissions, medical school affiliation and occupancy rate-remained significant predictors of survival, while minority representation showed no significance. The authors believe there has been enough change in minority representation since 1980 that the 1980 values used to conduct the study are no longer accurate predictors for this characteristic. Within the next six months, Sager and Socolar will run the numbers again using 1990 values, which they expect to show a significant connection between hospital reconfigurations and minority representation.
Sager and Sololar also created maps comparing surviving institutions with areas heavily populated by African-Americans and Latinos. These "spatial analyses" reinforced findings that hospital care has become less geographically accessible to many minority populations, the authors said. Sager said he believes some minorities are simply not getting needed care.
Based on 1980 levels of care, hospitals that remained open in 1995 also were found to be "substantially more costly" than those that closed or relocated. Cost per admission among surviving hospitals between 1980 and 1995 was $2,544, compared with $2,174 among institutions that closed or relocated, researchers reported.