SGEM Xtra: This is My Life – Centralization of Rural Emergency Healthcare

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Date: April 4th, 2023

Reference: Vaughan and Browne. Reconfiguring emergency and acute services: time to pause and reflect. BMJ Qual Saf. 2023 Apr

Guest Skeptics: Dr. Louella Vaugh is an internist practising as a hospitalist physician at an academic centre in London, UK with a special interest in smaller, rural and remote healthcare. Her main job is working for a think tank.

John Brown PhD is a Professor of Health Services Research in Ireland who has been studying rural healthcare issues since 2012.

This is an SGEM Xtra episode. There have been many “temporary” rural emergency department closures during the past last year. In Ontario alone there have been approximately 160 emergency departments (ED) temporarily closed since the beginning of 2022. This is something that has only happened once since 2006 (Ottawa Citizen March 28, 2023)

The study referred to in the editorial looks at the experience in Denmark with a reconfiguration of their emergency healthcare services (Flojstrup et al 2023). The objective of that study was the following:

To investigate how the’ natural experiment’ of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock.

It was a stepped-wedge reconfiguration of the entire Danish emergency healthcare system. The main outcome was the adjusted odds ratio for in-hospital mortality and hazard ratio for 30-day mortality with some pre-specified subgroups. They found no statistical difference for in-hospital mortality but slightly increased 30-day mortality. The pre-specified subgroup analyses showed a decrease in in-hospital or 30-day mortality for myocardial infarction, stroke, aortic aneurysm, and major trauma but not for pneumonia, bowel perforation or hip fractures.

This was not the only study to come out of the Danish reconfiguration initiative. The dataset also reported increasing admissions, mixed results on length of stay, increasing readmission rates, increasing COPD deaths if transported by ambulance, and expected productivity benefits were not realized.

The SGEM advocated for having the evidence to inform/guide our decisions. Here is what the evidence say about the centralization of emergency healthcare services from the Danish study:

some possible benefits for small groups of patients (myocardial infarction, stroke, aortic aneurysm, major trauma), there was no overall improvement in the in-hospital mortality trend and a slight worsening of the 30-day mortality trend.

Five Assumptions Made about Emergency Healthcare Centralization

Listen to the SGEM podcast to hear Louella and John discuss the five assumptions. Listed are the assumptions and some of the points we touched upon.

Assumption#1: There is a problem with the quality of EM care that needs to be fixed

1. Boarded patients length of stay (LOS) in the ED increases mortality
2. Canary in the coal mine (fix the mine not the canary)
3. COVID19 and staffing
4. It’s about a system problem not a small hospital problem

Assumption#2: Smaller hospitals provide worse care than their larger counterparts

1. Myocardial infarction, stroke, and major trauma account for 1% of ED attendance
2. Other skilled time-sensitive interventions (abdominal, vascular, obstetrical, and intracranial surgeries) still only amount to a total of 5% of ED attendance
3. Little or no evidence that care in small hospitals is worse for 95% of cases

Assumption#3: Reconfiguration produces better outcomes

1. While studies of centralisation of care for individual services show better outcomes for specific patient groups, the population-level evidence for whole-scale reconfiguration through changes to ED services tells a different story.
2. Two European studies and several studies in the USA. Renee Hsia has been looking at the impact of rounds of closures in California for nearly 20 years. At least 2 other national studies were conducted in the USA. There is also good evidence relating to the impact of service closure especially on maternity services
3. Other studies have demonstrated that hospital closures affect socioeconomic, geographical and ethnic groups differently, with the burden of closures falling most heavily on the more vulnerable

Assumption#4: Remaining organizations are minimally affected by reconfiguration
1. Evidence suggests that the remaining hospitals often suffer from substantial negative ‘spillover effects’, with overall mortality actually rising for their emergency patients
2. ED overcrowding with consequent increases in waiting times on trollies, increases in the pressures on ambulances services (time on the road, incidents and various other forms of ‘operational strain’.
3. The biggest problems currently facing acute and emergency services internationally are rising admissions and overcrowding; These studies strongly suggest that removing any capacity from an already overstretched system is likely to do harm.

Assumption#5: Reconfiguration has other benefits and no unintended consequences

1. Qualitative studies strongly suggest that facility closures and mergers produce permanent losses to the workforce—both to the region, as skilled workforce members move away, and permanently, as workers either retire early or seek other work
2. The closure or downgrading of EDs in small hospitals tends to be accompanied by the removal of other ‘front door’ services, such as general medicine, general surgery and obstetrics, as well as therapy and support services. (geographical ‘deserts of care’
3. These predominantly impact the older and poorer patients who live in rural and peripheral communities, urban areas are not wholly immune, with burden again falling disproportionately on the most vulnerable.
4. Health facilities are important to community identity, and their removal can lead to hidden psychological and social costs beyond the pragmatic concerns about poorer access to healthcare

Rural Mailbox

Keener Contest: Last weeks’ winner was Dave Michaleson a PA. He knew the longest time a human has remained awake is 264 hours. This is not a contest and we do not want anyone to try to break this record. There is no keener contest question this week.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication with a keener question. We will continue to try and cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based upon the best evidence.