According to current estimates, the annual number of ED visits in the United States increased by 51% between 1996 and 2009. During that time, the number of EDs nationwide decreased by 6%. “Throughout the country, ED closures are placing significant strains on emergency healthcare because they decrease access to care,” says Charles Liu.

In a study published in Health Affairs, Liu, Renee Y. Hsia, MD, MSc, and colleagues investigated the effects of ED closings on surrounding communities. The researchers identified all ED closures in California from 1999 to 2010 and examined their association with inpatient mortality rates at nearby hospitals. During the study period, 48 EDs across the state closed their doors. During that time, more than 16 million patients were admitted to hospitals from the ED and about 25% were cared for in close proximity to a recently closed ED.

“Overall, patients who were admitted to hospitals in the vicinity of an institution that had closed its ED had a 5% greater likelihood of inpatient mortality than those admitted to unaffected hospitals,” Liu says. The risk of death was more pronounced for non-elderly patients and patients with time-sensitive conditions, such as acute myocardial infarction (AMI), stroke, and sepsis. The odds of mortality increased by 10% for non-elderly adults, 15% for those with AMI, 10% for patients with stroke, and 8% for those with sepsis.

Important Implications

Given the trend of fewer EDs and a growing number of emergency patients nationwide, understanding the impact of ED closures is more important than ever. Past research has shown that EDs are more likely to close at hospitals with negative profit margins and in neighborhoods with more low-income and racial and ethnic minority patients, providing important context for the findings of this study. “The closure of EDs increases strain on surrounding EDs and adversely impacts patients who depend on them,” says Liu. “Such closures may widen healthcare disparities by further reducing access to care in communities that are already characterized as having vulnerable patients and underpaid hospitals.”

The mortality increases observed in the study by Liu and colleagues may be attributed to longer travel times to farther EDs or increased wait times and crowding in EDs located near a closure, although further research is needed to elucidate these links. “ED closures have ripple effects that should be considered when health systems and policy makers decide how to regulate these closures,” Liu says. “Each state has different requirements on how to regulate these closures, but it’s important to recognize the impact it can have on patient outcomes. As it stands now, the people who appear to be at highest risk are the same people who are most vulnerable, including those with lower socioeconomic status, who are underinsured, and who require urgent medical care.”


Liu C, Srebotnjak T, Hsia RY. California emergency department closures are associated with increased inpatient mortality at nearby hospitals. Health Aff (Millwood). 2014;33:1323-1329. Available at:

Hsia RY, Srebotnjak T, Maselli J, Crandall M, McCulloch C, Kellermann AL. The association of trauma center closures with increased inpatient mortality for injured patients. J Trauma Acute Care Surg. 2014;76:1048-1054.

Hsia RY, Kellermann AL, Shen YC. Factors associated with closures of emergency departments in the United States. JAMA. 2011;305:1978-1985.

Herring AA, Johnson B, Ginde AA, et al. High-intensity emergency department visits increased in California, 2002-09. Health Aff (Millwood). 2013;32:1811-1819.