87 Imbalance in US Emergency Department Openings and Closures Over 18 Years of Increasing Demand for Emergency Care: 2001 to 2018

Abstract

Emergency departments (EDs) provide 24/7 emergency care and also serve as a health care “safety net.” Rising dependence on this safety net role has heightened concern about the impact of ED closures on access to health care. We examined ED openings and closures, in both urban and non-urban areas, in the US between 2001 and 2018. We created the 2018 National ED Inventory (NEDI)-USA using data collected from a national survey of non-specialty, non-federal US EDs and compared it to the 2001 NEDI-USA database of similar design. We classified ED urban status using county-based Urban Influence Codes (UIC). We collapsed UIC categories into four groupings, one urban area and three non-urban areas: adjacent to urban, large non-adjacent and small non-adjacent. We also characterized EDs by US region, freestanding ED, Critical Access Hospital Program (CAHP) and Council of Teaching Hospital (COTH). Multivariable logistic regression with generalized estimating equations was used to identify ED characteristics independently associated with closure. In 2018, there were 5,514 US EDs. Among the 4,435 EDs open in both 2001 and 2018, 82% reported increases in visit volume; the typical ED saw a median of 16,146 visits (interquartile range [IQR] 6,837- 30,179) in 2001 vs 23,725 visits (IQR 9,000-47,450) in 2018 (P<0.001), an increase of 47%. Overall, including all US EDs in a given year, there were 101.1 million ED visits in 2001 vs 159.0 million in 2018 (+57%). Over the 18-year period, a total of 1,079 EDs opened while 449 closed; representing a net gain of 630 EDs or 13%. Urban areas had the largest net ED gain of 685 EDs (997 openings, 312 closures), while non-urban areas showed a net loss of 55 EDs (82 opening, 137 closures). Regionally, net ED gains were observed in the Midwest (155 openings, 95 closures), South (708 openings, 185 closures), and West (193 openings, 70 closures); the Northeast was the only region to experience a net loss in EDs (23 openings, 99 closures). A large ED increase was observed among freestanding EDs, gaining 648 EDs (661 openings, 13 closures), an increase of 1,322%. CAHP EDs experienced a net loss of 4 EDs (44 openings, 48 closures), and COTH EDs experienced a net loss of 24 EDs (3 openings, 27 closures). In a multivariable model with annual ED visit volume, urban location, US region, freestanding ED, CAHP status, and COTH status, ED closure was more likely in the Northeast (OR 1.47, as compared to South; 95% CI, 1.16-1.86). ED closure was less likely in EDs with larger annual visit volumes (OR 0.95 per 1,000 visits, 95% CI 0.94-0.95); non-urban settings, as compared to urban areas (adjacent to urban OR 0.42, 95% CI 0.33-0.54; large rural OR 0.32, 95% CI 0.20-0.52; small rural OR 0.23, 95% CI 0.15-0.35), and among CAHP EDs (OR 0.15, 95% CI 0.10-0.21). Freestanding and COTH EDs were not associated with ED closure. Most EDs that closed were the result of a financial decision (74%). Other primary reasons for closure were merger/consolidation (11%), conversion to another facility type (7%; eg, urgent care center with limited hours), and other reasons (8%; eg, natural disaster). Between 2001 and 2018, NEDI-USA data showed a net gain in US EDs (+13%) but a much larger increase in annual ED visit volume (+57%). While the total number of US EDs continues to rise, especially EDs in urban areas and freestanding EDs, ED openings are not keeping pace with the growing demand for emergency care.