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Journal Club Reading and Presentation Form 1. Reference: Factors associated with closures of EDs in the USA Hsia et al, 2011. From JAMA 2. Hypothesis: “to determine hospital, community, and market factors assoc’d with ED closures” 1. Methods (circle) DESIGN DESCRIPTIVE STUDIES Prospective Correlational Retrospective Case Report(s) Randomized Cross-sectional survey Non-randomized Cohort Non-blinded Case-Control Single blinded Interventional Double blinded Other: observational 4. Results and 5. Conclusion(s) Primary outcome: “number of hospital EDEs in nonrural areas declined by 27%, with for-profit ownership, location in competitive market, safety-net status, and low profit margin assoc’d with increased risk of ED closure” Secondary outcome – Also those that had poor pts, were smaller, and treated more minorities also more likely to close Does the hypothesis hold? – As a whole, the complication rate was decreased, though not for any 1 complication in particular. – Can conclude that being in a smoking cessation program will decrease complication rates, but CANNOT say that quitting smoking will decrease rates. We weren’t watching them so we cannot know for sure that they quit. – NNT = 5.5 (low!) Bias…..Type? Selection Observer Recall Other No conflicts of interest reported Review of disclosure statements: Authors got $$ from Swedish National Institute of Public Health and the Stockholm County Council Research Fund and Pfizer and Bactiguard AB Ways to improve the study?

Study Population n = 2446 1779 All general acute nonrural short-stay hospitals in the US with an operating ED from 1999-2009 Inclusion criteria see above Exclusion criteria: Hospitals that were not in metropolitan statistical areas (“critical access hospitals” operate under different federal mandates) Measurements erm

Main outcome variables : closed/not closed….

– – Did not examine federal hospitals (like VHA) Financial data stopped at 2007 Notes: – EMTALA: Emergency Medical Treatment and Labor Act: requires EDs to treat anyone. Must stabilize at least. Before any transfer, physician must speak with a physician at destination. This is an unfunded mandate. – A safety net receives govt $$. In this study, it is defined as a hospital that sees >/= double its share of Medicare/caid pts compared to other hospitals in a 15 mi radius – The study was limited in being retrospective: authors did not get to choose which factors to examine; they had to work with the data available. – Federally qualified healthcare center: underserved area. Get better reimbursement from govt. – Teaching hospitals also get federal $$ for teaching MD’s – Majority of care in uninsured pts occurs in the ER – “emergency” is now defined as whatever a reasonable pt would think. Some insurances make you call ahead to verify it’s a real emergency and will be covered! – Data was acquired through AHA annual surveys merged with Medicare hospital cost reports through 2007