A survey finds that as short-term, general hospitals close, the number of U.S. EDs also drops.
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| Phillip Kletke |
Many of the nation’s leading newspapers have featured alarming reports about severe overcrowding in hospital emergency departments. A number of factors have contributed to the growth in ED overcrowding, such as stricter enforcement of the Emergency Medical Treatment and Active Labor Act (EMTALA), shortages of nurses and other ED personnel, and the boarding of patients in the ED while they wait to be admitted to the hospital. Another important factor is a decline in the number of EDs during a time when the demand for emergency medical care is growing rapidly.
The Health Research and Educational Trust (HRET) used data from the AHA’s annual survey of U.S. hospitals to track trends in the total numbers of ED hospitals and emergency visits from 1990 to 2004. This study focused on nonfederal, short-term, general hospitals.
The decrease in the number of ED hospitals parallels the overall decline in the total number of short-term general hospitals. This trend, which began in the 1980s, is largely due to hospital closures and mergers brought about by the advent of managed care. Between 1990 and 2004, the number of nonfederal, short-term general hospitals with an ED fell from 5,048 to 4,422, a decrease of 12 percent (see Table 1 below). This decline was driven by a decrease in the total number of hospitals, not by a change in the proportion of hospitals with EDs. During this same period, the U.S. population grew by 18 percent. As a result, the number of ED hospitals per million population decreased by 26 percent.
Our findings do not indicate that hospitals have backed away from the provision of emergency services. In fact, the overwhelming majority of hospitals continue to have EDs, and the proportion of hospitals with EDs--around 96 percent--actually increased slightly between 1990 and 2004.
It’s interesting to note that the number of hospitals with trauma centers increased from 678 to 1,604 during the same period, an increase of 137 percent. Trauma center hospitals have EDs that are especially equipped to provide the very intense emergency services needed by trauma patients and accident victims. The proportion of hospitals with trauma centers rose from 13 percent to 35 percent, and the number of trauma center hospitals per million population doubled. So while general ED services, which often include less intense, nonemergent care, has declined, the availability of the very intense services provided by trauma centers has increased in recent years.
The rate at which people visited EDs increased significantly. Between 1990 and 2004, the aggregate number of emergency visits rose by 30 percent. This increase was driven jointly by the growth in the U.S. population and by a 10 percent increase in the annual number of ED visits per capita.
As a result of both greater ED utilization and the smaller number of ED hospitals, the number of emergency visits per ED hospital increased by almost 50 percent. This trend has pressured hospitals to increase ED capacity by adding more ED beds and treatment spaces.
Our study showed that some hospitals are more likely than others to have an ED (see Table 2 below). In 2004, private, for-profit hospitals were less likely to have an ED than private, nonprofit hospitals and hospitals owned by state and local governments. Small hospitals with fewer than 50 beds were less likely to have an ED than larger hospitals, and hospitals in large metropolitan areas were less likely to have an ED than those in nonmetropolitan areas. Hospitals in the West and South census regions were less likely to have EDs than hospitals in other regions of the United States.
ED availability also has changed in recent years with respect to census region and community size (see Table 3 below). The decrease in the number of ED hospitals per million population between 1990 and 2004 was greater in large metropolitan areas than in small metropolitan and nonmetropolitan areas. Also, the decreases in the West and South were larger than in the Northeast and North-Central census region. Because the West and South census regions have experienced large rates of population growth, these differences may be driven, in large part, by such growth.
In 2004, the annual number of emergency visits per ED hospital was more than three times greater in both large and small metropolitan areas than in nonmetropolitan areas, and it was considerably greater in the Northeast than in the rest of the country. The percent increase in the number of emergency visits per ED hospital varied considerably by census region, ranging from 33 percent in the Northeast to 60 percent in the South. However, it varied relatively little with respect to community size.
It is quite likely that the number of ED visits will continue to rise. Most of the past increases in the number of ED visits have been due to the growth of the U.S. population, which is projected to continue. And as the population ages, ED visits will likely increase because the over-65 population uses emergency services more frequently than other age groups. However, several recent trends may have decreased overcrowding in hospital EDs. The number of urgent care centers and ambulatory surgical centers has rapidly grown in recent years. These centers treat many patients who would otherwise receive care at hospital EDs. If it were not for the growth in this sector of the health delivery system, ED overcrowding would likely be even more severe.
Phillip Kletke, Ph.D., is a former director, health systems studies, at the Health Research and Educational Trust.
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|
1990
|
1995
|
2000
|
2004
|
Percent change,
1990-2004 |
|
| Hospitals' ED capacity | |||||
| Number of hospitals |
5,244
|
4,950
|
4,662
|
4,621
|
-12% |
| Number of hospitals with ED |
5,048
|
4,730
|
4,517
|
4,422
|
-12% |
| Number of hospitals with trauma center |
678
|
986
|
1,540
|
1,604
|
137% |
| Number of hospital beds (1,000s) |
912
|
847
|
800
|
781
|
-14% |
| Percent of hospitals with ED |
96%
|
96%
|
97%
|
96%
|
-- |
| Percent of hospitals with trauma center |
13%
|
20%
|
33%
|
35%
|
-- |
| Population (millions) |
249
|
263
|
281
|
294
|
18% |
|
Per capita measures |
|||||
| ED hospitals per million pop. |
20.3
|
18.0
|
16.1
|
15.1
|
-26% |
| Trauma center hospitals per million pop. |
2.7
|
3.8
|
5.5
|
5.5
|
101% |
|
ED utilization |
|||||
| Hospital ED visits (millions) |
87
|
94
|
103
|
112
|
30% |
| ED visits per 1,000 pop. |
347.8
|
358.1
|
365.4
|
382.0
|
10% |
| ED visits per ED hospitals (1,000s) |
17.1
|
19.9
|
22.8
|
25.4
|
48% |
Source: AHA Annual Hospital File, 1990, 1995, 2000 and 2004.
Note: Analysis is limited to nonfederal, short-term, general hospitals.
|
Total number of hospitals
|
Number
of hospitals with ED |
Percent of hospitals
with ED |
|
|---|---|---|---|
|
Total
|
4,621
|
4,422
|
95.7% |
| Ownership | |||
| State-local government |
1,102
|
1,065
|
96.6% |
| Private not-for-profit |
2,825
|
2,743
|
97.1% |
| Private for-profit |
694
|
614
|
88.5% |
| Hospital size | |||
|
6-49 beds
|
1,249
|
1,170
|
93.6% |
|
50-99 beds
|
899
|
861
|
95.8% |
|
100-199 beds
|
1,088
|
1,036
|
95.2% |
|
200-299 beds
|
610
|
594
|
97.3% |
|
300+ beds
|
775
|
761
|
98.2% |
| Community size | |||
| Non-metro |
2,130
|
2,080
|
97.6% |
| Small metro |
1,058
|
1,004
|
94.9% |
| Large metro |
1,433
|
1,338
|
93.4% |
| Census region | |||
| Northeast |
621
|
608
|
97.9% |
| North central |
1,358
|
1,335
|
98.3% |
| South |
1,777
|
1,703
|
95.9% |
| West |
865
|
775
|
89.6% |
Source: AHA Annual Hospital File, 2004.
Note: Analysis is limited to nonfederal, short-term, general hospitals.
| ED hospitals per million population | |||
|---|---|---|---|
| 1990 | 2004 | Percent change | |
| Total U.S. |
20.3
|
15.1
|
-26% |
| Community size | |||
| Non-metro |
45.6
|
37.4
|
-18% |
| Small metro |
16.8
|
12.4
|
-26% |
| Large metro |
12.5
|
8.5
|
-32% |
| Census region | |||
| Northeast |
14.3
|
11.1
|
-22% |
| North central |
25.1
|
20.3
|
-19% |
| South |
22.2
|
16.1
|
-28% |
| West |
17.6
|
11.5
|
-35% |
|
Annual number of ED visits (1,000s) per ED hospital
|
|||
| 1990 | 2004 | Percent change | |
| Total U.S. |
17.1
|
25.4
|
48% |
| Community size | |||
| Non-metro |
7.6
|
11.2
|
48% |
| Small metro |
22.3
|
33.8
|
51% |
| Large metro |
26.6
|
41.0
|
54% |
| Census region | |||
| Northeast |
27.2
|
36.2
|
33% |
| North central |
13.9
|
19.6
|
40% |
| South |
16.2
|
25.9
|
60% |
| West |
16.4
|
25.7
|
57% |
Source: AHA Annual Hospital File, 1990 and 2004.
Note: Analysis is limited to nonfederal, short-term, general hospitals.
This article 1st appeared on August 1, 2006 in HHN Magazine online site.
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