Rising Rate of Rural Hospital Closures Kaufman, Brystana G.; Thomas, Sharita R.; Randolph, Randy K. ...
The Journal of rural health,
Winter 2016, Volume:
32, Issue:
1
Journal Article
Peer reviewed
PURPOSE: Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and ...the impact on rural communities. METHODS: The 2009 financial performance and market characteristics of rural hospitals that closed from 2010 through 2014 were compared to rural hospitals that remained open during the same period, stratified by critical access hospitals (CAHs) and other rural hospitals (ORHs). Differences were tested using Pearson's chi‐square (categorical variables) and Wilcoxon rank test of medians. The relationships between negative operating margin and (1) market factors and (2) utilization/staffing factors were explored using logistic regression. FINDINGS: In 2009, CAHs that subsequently closed from 2010 through 2014 had, in general, lower levels of profitability, liquidity, equity, patient volume, and staffing. In addition, ORHs that closed had smaller market shares and operated in markets with smaller populations compared to ORHs that remained open. Odds of unprofitability were associated with both market and utilization factors. Although half of the closed hospitals ceased providing health services altogether, the remainder have since converted to an alternative health care delivery model. CONCLUSIONS: Financial and market characteristics appear to be associated with closure of rural hospitals from 2010 through 2014, suggesting that it is possible to identify hospitals at risk of closure. As closure rates show no sign of abating, it is important to study the drivers of distress in rural hospitals, as well as the potential for alternative health care delivery models.
Purpose
Annual rates of rural hospital closure have been increasing since 2010, and hospitals that close have poor financial performance relative to those that remain open. This study develops and ...validates a latent index of financial distress to forecast the probability of financial distress and closure within 2 years for rural hospitals.
Methods
Hospital and community characteristics are used to predict the risk of financial distress 2 years in the future. Financial and community data were drawn for 2,466 rural hospitals from 2000 through 2013. We tested and validated a model predicting a latent index of financial distress (FDI), measured by unprofitability, equity decline, insolvency, and closure. Using the predicted FDI score, hospitals are assigned to high, medium‐high, medium‐low, and low risk of financial distress for use by practitioners.
Findings
The FDI forecasts 8.01% of rural hospitals to be at high risk of financial distress in 2015, 16.3% as mid‐high, 46.8% as mid‐low, and 28.9% as low risk. The rate of closure for hospitals in the high‐risk category is 4 times the rate in the mid‐high category and 28 times that in the mid‐low category. The ability of the FDI to discriminate hospitals experiencing financial distress is supported by a c‐statistic of .74 in a validation sample.
Conclusion
This methodology offers improved specificity and predictive power relative to existing measures of financial distress applied to rural hospitals. This risk assessment tool may inform programs at the federal, state, and local levels that provide funding or support to rural hospitals.
The federal government uses multiple definitions for identifying rural communities based on various geographies and different elements of rurality.
The objectives of this study were to: (1) assess ...the degree to which rural definitions identify the same areas as rural; and (2) assess rural-urban disparities identified by each definition across socioeconomic, demographic, and health access and outcome measures.
We determined the rural status of each census tract and calculated the rural-urban disparity resulting from each definition, as well as across the number of definitions in which tracts were designated as rural (rurality agreement).
The population in 72,506 census tracts.
We used 8 federal rural definitions. Population characteristics included percent with a bachelor's degree, income below 200% poverty, population density, percent with health insurance and whether various health care services were within 30 minutes driving time of the tract centroid.
The rural population varied from slightly < 6.9 million people to >75.5 million across definitions. The largest rural-urban disparities were found using Urban Influence Codes. Urbanized Area and Urbanized Cluster tended to generate smaller disparities. Population characteristics such as population density and percent White had notable discontinuities across levels of rurality, while others such as percent with a bachelor's degree and income below 200% poverty varied continuously.
Rural-urban populations and disparities were sensitive to the specific definition and the relative strength of definitions varied across population characteristics. Researchers and policymakers should carefully consider the choice of outcome and region when deciding the most appropriate rural definition.
We surveyed the genetic diversity among avian influenza virus (AIV) in wild birds, comprising 167 complete viral genomes from 14 bird species sampled in four locations across the United States. These ...isolates represented 29 type A influenza virus hemagglutinin (HA) and neuraminidase (NA) subtype combinations, with up to 26% of isolates showing evidence of mixed subtype infection. Through a phylogenetic analysis of the largest data set of AIV genomes compiled to date, we were able to document a remarkably high rate of genome reassortment, with no clear pattern of gene segment association and occasional inter-hemisphere gene segment migration and reassortment. From this, we propose that AIV in wild birds forms transient "genome constellations," continually reshuffled by reassortment, in contrast to the spread of a limited number of stable genome constellations that characterizes the evolution of mammalian-adapted influenza A viruses.
The frequency of pulmonary vein stenosis (PVS) after ablation for atrial fibrillation has decreased, but it remains a highly morbid condition. Although treatment strategies including pulmonary vein ...dilation and stenting have been described, the long-term impacts of these interventions are unknown. We evaluated the presentation of severe PVS, and examined the risk for restenosis after intervention using either balloon angioplasty (BA) alone or BA with stenting.
This was a prospective, observational study of 124 patients with severe PVS evaluated between 2000 and 2014.
All 124 patients were identified as having severe PVS by computed tomography in 219 veins. One hundred two patients (82%) were symptomatic at diagnosis. The most common symptoms were dyspnea (67%), cough (45%), fatigue (45%), and decreased exercise tolerance (45%). Twenty-seven percent of patients experienced hemoptysis. Ninety-two veins were treated with BA, 86 were treated with stenting, and 41 veins were not treated. A 94% acute procedural success rate was observed and did not differ by initial management. Major procedural complications occurred in 4 of the 113 patients (3.5%) who underwent invasive assessment, and minor complications occurred in 15 patients (13.3%). Overall, 42% of veins developed restenosis including 27% of veins (n=23) treated with stenting and 57% of veins (n=52) treated with BA. The 3-year overall rate of restenosis was 37%, with 49% of BA-treated veins and 25% of stented veins developing restenosis (hazard ratio, 2.77; 95% confidence interval, 1.72-4.45; P<0.001). After adjustment for age, CHA2DS2-VASc score, hypertension, and the time period of the study, there was still a significant difference in the risk of restenosis for BA versus stenting (hazard ratio, 2.46; 95% confidence interval, 1.47-4.12; P<0.001).
The diagnosis of PVS is challenging because of nonspecific symptoms and the need for dedicated pulmonary vein imaging. There is no difference in acute success by type of initial intervention; however, stenting significantly reduces the risk of subsequent pulmonary vein restenosis in comparison with BA.
Purpose
The purpose of this study is to describe the characteristics of Rural Residency Planning and Development (RRPD) Programs, compare the characteristics of counties with and without RRPD ...programs, and identify rural places where future RRPD programs could be developed.
Methods
The study sample comprised 67 rural sites training residents in 40 counties in 24 US states. Descriptive statistics were used to describe RRPD programs and logistic regression to predict the probability of a county being an RRPD site as a function of population, primary care physicians (PCP) per 10,000 population, and the social vulnerability index (SVI) compared to a control sample of nonmetro counties without RRPD sites.
Findings
Most RRPD grantees (78%) were family medicine programs affiliated with medical schools (97%). RRPD counties were more populous (P<.01), had a higher population density (P<.05), and a higher percent of the non‐White or Hispanic population (P = .05) compared to non‐RRPD counties. Both higher population (P<.001) and PCP ratio (P = .046) were strong predictors, while SVI (P = .07) was a weak predictor of being an RRPD county.
Conclusions
RRPD sites appear to represent a “sweet spot” of rural counties that have the population and physician supply to support a training program but also are relatively more socially vulnerable with high‐need populations. Additional counties fitting this “sweet spot” could be targeted for funding to address health disparities and health workforce maldistribution.
Evidence is increasing of a link between interferon (IFN) and pulmonary arterial hypertension (PAH). Conditions with chronically elevated endogenous IFNs such as systemic sclerosis are strongly ...associated with PAH. Furthermore, therapeutic use of type I IFN is associated with PAH. This was recognized at the 2013 World Symposium on Pulmonary Hypertension where the urgent need for research into this was highlighted.
To explore the role of type I IFN in PAH.
Cells were cultured using standard approaches. Cytokines were measured by ELISA. Gene and protein expression were measured using reverse transcriptase polymerase chain reaction, Western blotting, and immunohistochemistry. The role of type I IFN in PAH in vivo was determined using type I IFN receptor knockout (IFNAR1(-/-)) mice. Human lung cells responded to types I and II but not III IFN correlating with relevant receptor expression. Type I, II, and III IFN levels were elevated in serum of patients with systemic sclerosis associated PAH. Serum interferon γ inducible protein 10 (IP10; CXCL10) and endothelin 1 were raised and strongly correlated together. IP10 correlated positively with pulmonary hemodynamics and serum brain natriuretic peptide and negatively with 6-minute walk test and cardiac index. Endothelial cells grown out of the blood of PAH patients were more sensitive to the effects of type I IFN than cells from healthy donors. PAH lung demonstrated increased IFNAR1 protein levels. IFNAR1(-/-) mice were protected from the effects of hypoxia on the right heart, vascular remodeling, and raised serum endothelin 1 levels.
These data indicate that type I IFN, via an action of IFNAR1, mediates PAH.
To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke.
Cross-sectional analysis of data for 2 years ...(2005-2006) from the State Inpatient Databases.
All short-term acute-care hospitals in 4 demographically and geographically diverse states.
Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic.
Not applicable.
(1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply.
Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location.
Several sociodemographic and geographic disparities in PARC use were identified.
Objectives
To assess and compare the associations between socioeconomic status (SES) measures from two sources (claims vs. survey data) and the type of post‐acute care (PAC) locations following ...hospital discharge.
Methods
This observational study included Medicare Fee‐for‐Service (FFS) beneficiaries age 65.5 years or older who participated in the Medicare Current Beneficiary Survey (MCBS) and were hospitalized in 2006–2011. Multiple data sets were used including: Area Deprivation Index; Medicare Cost Reports, Provider of Services files, and Area Health Resource File. Multinomial regression models estimated associations between beneficiary's SES and PAC type. SES measures came from surveys (income and education) and administrative records (dual enrollment and area deprivation). PAC types included home with self‐care, home health agency, skilled nursing facility (SNF), or inpatient rehabilitation facility.
Results
Low income and dual enrollment were associated with higher SNF use while living in a deprived area was associated with lower SNF use and higher use of home with self‐care. Dual enrollment and area deprivation were associated with the largest differences.
Conclusions
If policies to modify payment based on SES are considered, administrative measures (dual enrollment and area deprivation) rather than survey measures (education and income) may be sufficient.
Objective
To provide an updated analysis of the economic effects of rural hospital closures.
Study Setting
Our study sample was national in scope and consisted of nonmetro counties from 2001 to 2018.
...Study Design
We used a difference‐in‐differences study design to estimate the effect of a hospital closure on county income, population, unemployment, and size of the labor force. Specifically, we compared economic changes over time in nonmetro counties experiencing a hospital closure to changes in a control group of nonmetro counties over the same time period. We also leveraged insight from recent research to control for estimation bias due to heterogeneity in the closure effect over time or across groups defined by when closure was experienced.
Data Extraction
Data on (adjusted gross) annual income (in real dollars), annual population size, and monthly unemployment rate and labor force size were sourced from the Internal Revenue Service, Census Bureau, and Bureau of Labor Statistics, respectively. We used data from the North Carolina Rural Health Research Program to identify counties that experienced a hospital closure.
Principal Findings
Of the 1759 nonmetro counties in our study sample, 109 experienced a hospital closure during the study period. Relative to the nonclosure counterfactual, closures significantly decreased labor force size, on average, by 1.4% (95% CI: −2.1%, −0.8%). Results also suggest that Prospective Payment System (PPS) hospital closures significantly decreased population size, on average, by 1.1% (95% CI: −1.7%, −0.5%), relative to the nonclosure counterfactual.
Conclusions
Our analysis suggests that rural hospital closures often have adverse effects on local economic outcomes. Importantly, the negative economic effects of closure appear to be strongest following Prospective Payment System hospital closures and attenuated when the closed hospital is converted to another type of health care facility, allowing for the continued provision of services other than inpatient care.
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