Between 1996 and 2009 the annual number of emergency department (ED) visits in the United States increased by 51 percent while the number of EDs nationwide decreased by 6 percent, which placed unprecedented strain on the nation's EDs. To investigate the effects of an ED's closing on surrounding communities, we identified all ED closures in California during the period 1999-2010 and examined their association with inpatient mortality rates at nearby hospitals. We found that one-quarter of hospital admissions in this period occurred near an ED closure and that these admissions had 5 percent higher odds of inpatient mortality than admissions not occurring near a closure. This association persisted whether we considered ED closures as affecting all future nearby admissions or only those occurring in the subsequent two years. These results suggest that ED closures have ripple effects on patient outcomes that should be considered when health systems and policy makers decide how to regulate ED closures.

We examined the charges, their variability, and respective payer group for diagnosis and treatment of the ten most common outpatient conditions presenting to the Emergency department (ED).We conducted a cross-sectional study of the 2006-2008 Medical Expenditure Panel Survey. Analysis was limited to outpatient visits with non-elderly, adult (years 18-64) patients with a single discharge diagnosis.We studied 8,303 ED encounters, representing 76.6 million visits. Median charges ranged from $740 (95% CI $651-$817) for an upper respiratory infection to $3437 (95% CI $2917-$3877) for a kidney stone. The median charge for all ten outpatient conditions in the ED was $1233 (95% CI $1199- $1268), with a high degree of charge variability. All diagnoses had an interquartile range (IQR) greater than $800 with 60% of IQRs greater than $1550.Emergency department charges for common conditions are expensive with high charge variability. Greater acute care charge transparency will at least allow patients and providers to be aware of the emergency department charges patients may face in the current health care system.

Though Americans make 1.8 million asthma-related outpatient visits to the emergency department (ED) annually, little is known about the episodic charges for asthma care in the ED. We therefore sought to assess the bills patients could face for acute asthma incidents by examining hospital charges for asthma-related outpatient ED visits. We performed a nationwide, cross-sectional study of 2.9 million weighted asthma-related outpatient ED visits from 2006-2008 using data from the Medical Expenditure Panel Survey. We found that the average charge for an outpatient ED visit was $1,502 (95% CI $1,493-$1,511). The charges did not vary significantly by insurance group but did increase significantly with age. Our results indicate that the financial burden of ED care for asthma may take a severe toll on low-income populations who have limited ability to pay, especially patients who must pay undiscounted charges, including the uninsured and those on high-deductible health plans.

STUDY OBJECTIVE: We seek to determine whether patients living in areas affected by emergency department (ED) closure, with subsequent increased distance to the nearest ED, have a higher risk of inpatient death from time-sensitive conditions. METHODS: Using the California Office of Statewide Health and Planning Development database, we performed a nonconcurrent cohort study of hospital admissions in California between 1999 and 2009 for patients admitted for acute myocardial infarction, stroke, sepsis and asthma or chronic obstructive pulmonary disease. We used generalized linear mixed-effects models comparing adjusted inpatient mortality for patients experiencing increased distance to the nearest ED versus no change in distance. RESULTS: Of 785,385 patient admissions, 67,577 (8.6%) experienced an increase in distance to ED care because of an ED closure. The median change for patients experiencing an increase in distance to the nearest ED was only 0.8 miles, with a range of 0.1 to 33.4 miles. Patients with an increase did not have a significantly higher mortality (adjusted odds ratio 1.04; 95% confidence interval 0.99 to 1.09). In subgroups, we also observed no statistically significant differences in adjusted mortality among patients with acute myocardial infarction, stroke, asthma or chronic obstructive pulmonary disease, and sepsis. We did not observe any significant variations in mortality for time-sensitive conditions in sensitivity analyses that incorporated a lag effect of time after change in distance, allowance for a larger affected population, or removal of ST-segment elevation myocardial infarction from the acute myocardial infarction subgroup. CONCLUSION: In this large population-based sample, less than 10% of the patients experienced an increase in distance to the nearest ED, and of that group, the majority had less than a 1-mile increase. These small increased distances to the nearest ED were not associated with higher inpatient mortality among time-sensitive conditions.

Background

Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed.

Methods

We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure.

Results

The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51).

Conclusion

Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure.

Level of evidence

Prognostic and epidemiologic, level III.

Study objective

We seek to determine whether patients living in areas affected by emergency department (ED) closure, with subsequent increased distance to the nearest ED, have a higher risk of inpatient death from time-sensitive conditions.

Methods

Using the California Office of Statewide Health and Planning Development database, we performed a nonconcurrent cohort study of hospital admissions in California between 1999 and 2009 for patients admitted for acute myocardial infarction, stroke, sepsis and asthma or chronic obstructive pulmonary disease. We used generalized linear mixed-effects models comparing adjusted inpatient mortality for patients experiencing increased distance to the nearest ED versus no change in distance.

Results

Of 785,385 patient admissions, 67,577 (8.6%) experienced an increase in distance to ED care because of an ED closure. The median change for patients experiencing an increase in distance to the nearest ED was only 0.8 miles, with a range of 0.1 to 33.4 miles. Patients with an increase did not have a significantly higher mortality (adjusted odds ratio 1.04; 95% confidence interval 0.99 to 1.09). In subgroups, we also observed no statistically significant differences in adjusted mortality among patients with acute myocardial infarction, stroke, asthma or chronic obstructive pulmonary disease, and sepsis. We did not observe any significant variations in mortality for time-sensitive conditions in sensitivity analyses that incorporated a lag effect of time after change in distance, allowance for a larger affected population, or removal of ST-segment elevation myocardial infarction from the acute myocardial infarction subgroup.

Conclusion

In this large population-based sample, less than 10% of the patients experienced an increase in distance to the nearest ED, and of that group, the majority had less than a 1-mile increase. These small increased distances to the nearest ED were not associated with higher inpatient mortality among time-sensitive conditions.

BACKGROUND: Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed. METHODS: We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure. RESULTS: The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51). CONCLUSION: Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure. LEVEL OF EVIDENCE: Prognostic and epidemiologic, level III.

Helping the world's coastal communities adapt to climate change impacts requires evaluating the vulnerability of coastal communities and assessing adaptation options. This includes understanding the potential for 'natural' infrastructure (ecosystems and the biodiversity that underpins them) to reduce communities' vulnerability, alongside more traditional 'hard' infrastructure approaches. Here we present a spatially explicit global evaluation of the vulnerability of coastal-dwelling human populations to key climate change exposures and explore the potential for coastal ecosystems to help people adapt to climate change (ecosystem-based adaptation (EbA)). We find that mangroves and coral reefs are particularly well situated to help people cope with current weather extremes, a function that will only increase in importance as people adapt to climate change now and in coming decades. We find that around 30.9 million people living within 2km of the coast are highly vulnerable to tropical storms and sea-level rise (SLR). Mangroves and coral reefs overlap these threats to at least 5.3 and 3.4 million people, respectively, with substantial potential to dissipate storm surges and improve resilience against SLR effects. Significant co-benefits from mangroves also accrue, with 896 million metric tons of carbon stored in their soils and above- and below-ground biomass. Our framework offers a tool for prioritizing 'hotspots' of coastal EbA potential for further, national and local analyses to quantify risk reduction and, thereby, guide investment in coastal ecosystems to help people adapt to climate change. In doing so, it underscores the global role that conserving and restoring ecosystems can play in protecting human lives and livelihoods, as well as biodiversity, in the face of climate change.