Singularities, Odds Ratios, and Significance: California Emergency Department Closures and Los Angeles

Abstract

The conclusions of the earnest study by Hsia et al of the effect of emergency department (ED) closures on vulnerable populations between 1998 and 2008 are less about California than they are about Los Angeles, where most of the closures occurred. The authors demonstrated statistical acumen in deriving odds ratios from variables in a statewide database collected each year from acute care hospitals. But their approach to ED closures in Los Angeles did not take into account the complex interactions between markets, cultures, and politics in a landscape that is better understood as a city-state in our global community. The population of Los Angeles County alone is greater than that of 42 of the other 49 states in the United States and exceeds the population of Hong Kong, Singapore, or Dubai, surpassing them in diversity. The main counterargument about the effect of ED closures was carried by Melnick and Fonkych at RAND and the University of Southern California. Beginning with the same primary source of data used by Hsia et al, the California Office of Statewide Health Planning and Development, Melnick and Fonkych reported an increase of 17% in total ED capacity in terms of licensed beds between 2001 and 2007. They also reported that capacity increased more rapidly than the state population, though not as rapidly as overall ED visits, 19% and 15%, respectively. Hsia et al found that ED closures were more likely to occur at lower-volume EDs and for-profit hospitals, which is consistent with prevailing market forces in Los Angeles and elsewhere in California; the remaining hospitals continue to seek economies of scale through system consolidation and profitable service lines. In Darwinian terms, policymakers cannot compel less viable facilities left behind by stronger competitors to continue to remain open with operating losses. As the founders of one faith-based, not-for-profit hospital system famously preached, “No margin, no mission.” Because of the high density of hospitals in Los Angeles, Melnick and Fonkych also found that 44% of displaced ED patients had to travel only 2 more miles to reach the next closest i