Case Study: What Leads to the Closure of an Emergency Department?


Over the past few decades, there has been an increasing strain on emergency departments nationwide, with reports of crowding and delays in care for patients seeking care. Anecdotally, there have been reports that closures occur more frequently in poorer areas, which can result in larger disparities for more vulnerable populations, but this has not been proven. To better understand the forces driving, and inform policy efforts to combat this trend, we examined the factors associated with ED closure in non-rural areas between 1990 and 2007.


We analyzed ED and hospital data from the American Hospital Association (AHA) Annual Surveys and Medicare hospital cost reports from 1990-2007. Applying survival analysis techniques, we analyzed the influence of hospital, market, and population demographic factors on the likelihood that an ED closed during our study period. We found that hospitals serving large proportions of patients in poverty, “safety-net” hospitals (those serving a large share of poorly insured patients), and those with low profit margins were more likely to close their ED than their counterparts. For-profit hospitals and hospitals in more competitive markets also had a significantly higher risk of closing their EDs.


Our findings show that emergency departments’ solvencies are as vulnerable to market-based factors as other parts of the healthcare system. In part because EDs disproportionately serve uninsured or underinsured patients who cannot pay the full cost of the care, financial instability appears to drive a disproportionate number of EDs to close, resulting in disparities in access to life-saving care. These results underscore that markets cannot— and should not—be expected to fix a strained emergency care system, but rather are likely to exacerbate the issue.

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Study Reference:

Hsia RY, Kellermann AL, Shen Y-C. Factors associated with closures of emergency departments in the United States. JAMA. 2011;305(19):1978-1985. doi:10.1016/j.jemermed.2011.07.004.