Delays in seeking care among older urban community dwelling persons in South Los Angeles were significantly higher after the closure of the community’s major safety net hospital.
This study has four important limitations. The study used a pre-post design, with only one before and one after point and no control group. The observed variation may thus have been due to secular trends that were not controlled in this analysis. Patients were recruited from one area of Los Angeles County, South Los Angeles. In addition, delays and the use of preventive services were self-reported and may have contributed to potential response bias; however, we used prospectively collected and previously tested measures of self-reported delays. Finally, we do not know the health consequences of these self-reported delays. However, we used a community based-participatory research method to select these measures and the community stakeholders considered them to be very important.
Previous studies of the effect of hospital closure have focused on documenting differences in patient outcomes from administrative or survey data.9-11
Other studies focused on changes due to distance traveled,12-14
rural hospital closure,9,15-20
and staffing changes.21-23
Few studies have examined the impact of hospital closure on delays in care. Prior work has documented that health system changes are not the only reason to have delays in care. National rates show that almost 20% of the population has delayed or had difficulty getting needed medical care, and may be as high as 29% in low-income populations. 24-27
Our study contributes to this literature, strengthened by using community based participatory research methods.
To our knowledge, this study is the first to examine the impact of hospital closure using community based participatory methods. Our community partners and health policy leaders were able to leverage these results to inform ongoing efforts to improve health care services in South Los Angeles, particularly as efforts to re-open the hospital were underway.
To our knowledge, this study is the first to examine the impact of hospital closure using community based participatory methods.
Health reform has passed, and it is hard to know the repercussions that it will have on the safety net. After the signing of Medicare Act in 1965, patients aged >65 disappeared from county hospitals.9,10
In addition, changes in prenatal Medicaid rates moved much of obstetrical care out of county hospitals.11,12
The health reform bill may result in a large number of people in disadvantaged communities in 2014 becoming members of the Medicaid program. As public safety net hospitals across the country face multiple and growing challenges, including the loss of reimbursement for uninsured populations and simultaneous declines in the Medicaid funding, it is likely that pressures on public safety net hospitals will increase. This change may result in the closure of more public safety net hospitals or significant reductions in services, additional delays in care and difficulty improving quality care.
This research underscores the need for future measures to monitor progress toward improved access to care. Efforts to increase insurance coverage and coordinate care in accountable care organizations also need outcomes for monitoring progress. As shown in San Francisco, the safety net can also be a setting for innovation and high-quality integrated care.28
Using a medical home model may help to reduce or eliminate racial/ethnic health disparities29-31
that are often linked to the health effects of poverty.
In the setting of hospital closure, it is critical to monitor multiple outcomes to understand both the intended and unintended consequences of hospital closure. The use of community advisory boards, community clinic input, and local stakeholder community forums can help inform efforts to address the local impact of hospital closure, particularly for vulnerable populations.