The economic effects of rural hospital closures

What happens to rural hospitals during a ransomware attack? Evidence from Medicare data

PURPOSE

Hospitals are increasingly the target of cybersecurity threats, including ransomware attacks. Little is known about how ransomware attacks affect care at rural hospitals.

METHODS

We used data on hospital ransomware attacks from the Tracking Healthcare Ransomware Events and Traits database, linked to American Hospital Association survey data and Medicare fee-for-service (FFS) claims data from 2016 to 2021. We measured Medicare FFS volume and revenue in the inpatient, outpatient, and emergency room setting-at the hospital-week level. We then conducted a stacked event study analysis, comparing hospital volume and revenue at ransomware-attacked and nonattacked hospitals before and after attacks.

FINDINGS

Ransomware attacks severely disrupted hospital operations-with comparable effects observed at rural versus urban hospitals. During the first week of the attack, inpatient admissions volume fell by 14.7% at rural hospitals (P = .04) and 16.9% at urban hospitals (P = .01)-recovering to preattack levels within 2-3 weeks. Outpatient visits fell by 35.3% at rural hospitals (P<.01) and 22.0% at urban hospitals (P = .03) during the first week. Emergency room visits fell by 10.0% at rural hospitals (P = .04) and 19.3% at urban hospitals (P = .01). Travel time and distance to the closest nonattacked hospital was 4-7 times greater for rural ransomware-attacked hospitals than for urban ransomware-attacked hospitals.

CONCLUSIONS

Ransomware attacks disrupted hospital operations in rural and urban areas. Disruptions of similar magnitudes may be more detrimental in rural areas, given the greater distances patients must travel to receive care and the outsized impact that lost revenue may have on rural hospital finances.

Understanding the impacts of rural hospital closures: A scoping review

PURPOSE

Rural hospitals are closing at unprecedented rates, with hundreds more at risk of closure in the coming 2 years. Multiple federal policies are being developed and implemented without a salient understanding of the emerging literature evaluating rural hospital closures and its impacts. We conducted a scoping review to understand the impacts of rural hospital closure to inform ongoing policy debates and research.

METHODS

A comprehensive search strategy was devised by library faculty to collate publications using the PRISMA extension for scoping reviews. Two coauthors then independently performed title and abstract screening, full text review, and study extraction.

FINDINGS

We identified 5054 unique citations and assessed 236 full texts for possible inclusion in our narrative synthesis of the literature on the impacts of rural hospital closure. Twenty total original studies were included in our narrative synthesis. Key domains of adverse impacts related to rural hospital closure included emergency medical service transport, local economies, availability and utilization of emergency care and hospital services, availability of outpatient services, changes in quality of care, and workforce and community members. However, significant heterogeneity existed within these findings.

CONCLUSIONS

Given the significant heterogeneity within our findings across multiple domains of impact, we advocate for a tailored approach to mitigating the impacts of rural hospital closures for policymakers. We also discuss crucial knowledge gaps in the evidence base-especially with respect to quality measures beyond mortality. The synthesis of these findings will permit policymakers and researchers to understand, and mitigate, the harms of rural hospital closure.

The impact of rural general hospital closures on communities-A systematic review of the literature

PURPOSE

To compile the literature on the effects of rural hospital closures on the community and summarize the evidence, specifically the health and economic impacts, and identify gaps for future research.

METHODS

A systematic review of the relevant peer-reviewed literature, published from January 2005 through December 2021, included in the EMBASE, CINAHL, PubMed, EconLit, and Business Source Complete databases, as well as "gray" literature published during the same time period. A total of 21 articles were identified for inclusion.

FINDINGS

Over 90% of the included studies were published in the last 8 years, with nearly three-fourths published in the last 4 years. The most common outcomes studied were economic outcomes and employment (76%), emergent, and non-emergent transportation, which includes transport miles and travel time (42.8%), access to and supply of health care providers (38%), and quality of patient outcomes (19%). Eighty-nine percent of the studies that examined economic impacts found unfavorable results, including decreased income, population, and community economic growth, and increased poverty. Between 11 and 15.7 additional minutes were required to transport patients to the nearest emergency facility after closures. A lack of consistency in measures and definition of rurality challenges comparability across studies.

CONCLUSIONS

The comprehensive impact of rural hospital closures on communities has not been well studied. Research shows predominantly negative economic outcomes as well as increased time and distance required to access health care services. Additional research and consistency in the outcome measures and definition of rurality is needed to characterize the downstream impact of rural hospital closures.

The bystander effect: Impact of rural hospital closures on the operations and financial well-being of surrounding healthcare institutions

INTRODUCTION

There is presently a rural hospital shortage in the United States with 180 closures since 2005 and hundreds of institutions in financial peril. Although the hospital closure phenomenon is well-established, less is known about the spillover impact on the operations and financial wellbeing of surrounding hospitals. This preliminary study quantified how discrete rural hospital closures impact institutions in their regional proximity, finding a significant increase in inpatient admissions and emergency department visits for these "bystander hospitals".

METHODS

Using a repository of rural hospital closures collected by the UNC Sheps Center for Health Services Research, we identified closures over the past 15 years. Criteria for inclusion were hospitals that had been fully closed between 2005-2016 and with >25-bed capacity. We then designated surrounding hospitals within a 30-mile radius of each closed hospital as "bystander hospitals." We examined the average rate-of-change for inpatient admissions and emergency department visits in surrounding hospitals both two years before and after relevant hospital closures.

RESULTS

We identified 53 hospital closures and 93 bystander hospitals meeting our criteria during the study period. With respect to geographic distribution, 66% of closures were in the Southern US, including 21% in Appalachia. Average emergency department visits increased by 3.59% two years prior to a hospital's closure; however, at two years post-closure the average rate of increase rose to 10.22% (F (4,47) = 2.77, p = 0.0375). Average bystander hospital admissions fell by 5.73% in the two years preceding the hospital closure but increased 1.17% in the two years after (F (4,46) = 3.05, p = 0.0259).

CONCLUSION

These findings predict a daunting future for rural healthcare. While previous literature has described the acute effects hospital closures have on communities, this study suggests a significant spillover effect on hospitals within the geographic region and a cyclical process at play in the rural healthcare sector. In the absence of significant public health assistance in regions affected by closures, poor health outcomes, including "diseases of despair," are likely to continue proliferating, disproportionately affecting the most vulnerable. In the COVID-19 era, it will be especially necessary to focus on hospital closures given increased risk of maintaining solvency due to delayed and deferred care atop already tight margins.