Department  of Health  and Human  Services 
OFFICE OF

INSPECTOR GENERAL

HOSPITAL  CLOSURE:  1995

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 JUNE  GIBBS  BROWN 
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4+d3a OEI-04%00060  OFFICE  OF  INSPECTOR  GENERAL 
The  mission  of the  Office  of Inspector  General  (OIG),  as mandated  by Public  Law 
95-452, is to protect  the  integrity  of the  Department  of Health  and  Human  Services 
programs  as well as the  health  and  welfare  of beneficiaries  served  by them.  This 
statuto~  mission  is carried  out  through  a nationwide  program  of audits,  investigations, 
inspections,  sanctions,  and  fraud  alerts.  The  Inspector  General  informs  the  Secretary 
of program  and  management  problems  and  recommends  legislative,  regulatory,  and 
operational  approaches  to correct  them. 
Office  of  Evaluation  and Inspections 
The  Office  of Evaluation  and  Inspections  (OEI)  is one  of several  components  of the 
Office  of Inspector  General.  It conducts  short-term  management  and  program 
evaluations  (called  inspections)  that  focus on issues  of concern  to the  Department,  the 
Congress,  and  the  public.  The  inspection  reports  provide  findings  and 
recommendations  on the  efficiency,  vulnerability,  and  effectiveness  of departmental 
programs. 
The  OEIS Atlanta  Regional  Office  prepared  this report  under  the  direction  of Jesse  J. 
Flowers,  Regional  Inspector  General,  and  Christopher  Koehler,  Deputy  Regional 
Inspector  General.  Principal  OEI  staff included: 
Atlanta  Retion  Headmmrtem 
Ron  Kalil,  Team Leader  Winnie  Walker,  Program Specialist

Peggy Daniel,  Program Analyst  Linda  Moscoe,  Technical Suppoti

Jackie  Watkins,  Bogram  Analyst

Paula  Bowker,  Program AnaZyst

To  obtain  a copy of this report,  call the  Atlanta  Regional  Office  at  (404)  331-4108.  EXECUTIVE  SUMMARY

PURPOSE 
To  describe  the  extent,  characteristics,  and  impact  of hospital  closure  in  1995, 
BACKGROUND 
The  closure  ofhospitals  inpast  years  had  generated  public  and  congressional  concern. 
We  released  areport  in May  1989 describing  the  nationwide  phenomenon  ofhospital 
closurein  1987.  We  issued  subsequent  annual  reports  in  1988 through  1994. 
The  findings  from  all the  OIG  studies  of hospital  closure  are  similar.  The  hospitals  that 
closed  were  small  and  had  low occupancy  rates.  When  the  hospitals  closed,  few patients 
were  affected.  Most  could  get medical  care  nearby. 
FINDINGS 
Our  inspection  of hospital  closure  in 1995 produced  findings  similar  to those  previously 
reported  for  1987-1994. 
	 Thirty-seven  general,  acute  care  hospitals  closed.  This  is twenty-one  more  than  in 
1994 but  still less than  in any other  year  since we began  this series  of reports. 
Four  new general,  acute  care  hospitals  opened  in 1995, and  one  hospital  that 
closed  in  1991 reopened  in 1995. 
  Thirteen  of the  closed  hospitals  were  rural  and  24 were  urban. 
	 Closed  hospitals  in both  rural  and  urban  areas  were  smaller  than  the  national 
averages. 
Rural  hospitals  that  closed  had  an average  of 46 beds  as compared  to an 
average  of 74 beds  for all rural  hospitals  nationally. 
Urban  hospitals  that  closed  had  an average  of 110 beds  as compared  to an 
average  of 228 beds  for all urban  hospitals  nationally. 
i  	 Occupancy  rates  for closed  rural  and  urban  hospitals  were  lower  than  the  national 
averages. 
Rural  hospitals  that  closed  had  an average  occupancy  rateof  21.8 percent 
as comparedto  anaverageof33  .8 percent  fora11 rural  hospitals  nationally. 
The  average  daily census  in the  year  prior  to closure  was about  10 patients. 
Urban  hospitals  that  closed  hadan  average  occupancy  rate  of37.2  percent 
as comparedto  an  average  of 50.2 percent  for all urban  hospitals 
nationally.  The  average  daily census  in the  year  prior  toclosurewas41 
patients. 
	 Medicare  utilization  among  hospitals  that  closed  was slightly more  than  the 
national  average. 
In rural  areas,  the  average  Medicare  utilization  among  hospitals  that  closed 
was 58.1 percent  compared  to an average  of 57.1 percent  for  all rural 
hospitals  nationally.  About  6 Medicare  patients  were  in the  hospital  on an 
average  day in the  year  prior  to closure. 
In urban  areas,  the  average  Medicare  utilization  among  hospitals  that 
closed  was 54.6 percent  compared  to an average  of 48,8 percent  for all 
urban  hospitals  nationally.  About  22 Medicare  patients  were  in the 
hospital  on an average  day in the  year  prior  to closure. 
	 Medicaid  utilization  among  hospitals  that  closed  was less than  the  national 
average. 
In rural  areas,  the  average  Medicaid  utilization  among  hospitals  that  closed 
was 7.8 percent  as compared  to an average  of 11.9 percent  for  all hospitals 
nationally. 
In urban  areas,  the  average  Medicaid  utilization  among  hospitals  that 
closed  was  10.9 percent  as compared  to an average  of 13.9 percent  for all 
urban  hospitals  nationally. 
	 Although  residents  in a few communities  had  to travel  greater  distances  for 
hospital  care,  most  had  emergency  and  inpatient  medical  care  available  within  10 
miles  of a closed  hospital. 
	 At  the  time  of our  inspection,  17 of the  37 closed  hospital  facilities  (46 percent) 
were  being  used  for health-related  services.  Also,  plans  were  being  made  to use  3 
of the  remaining  17 vacant  hospitals  for health-related  services. 
ii  TABLE  OF  CONTENTS

ExEamvE  summary  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 i 
INTRODU(XION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....-
 1 
FINDINGS 
Extent  and  Characteristics  of Closed  Hospitals  . . . . . . . . . . . . . . . . . . . . . . . .
 3 
How  Many  Closed  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
 3 
Where  Were  They  . . . . . . . . . . . . . . . . . . . . . ..  OF. . . . . . . . . . . . . . . .
 4 
What  Were  They  Like  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 4 
Impact  ofHospital  Closure  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 7 
How  Many  Patients  Were  Affected  . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 7 
Are  Inpatient  Care  and  Emergency

Services  Available  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 8 
What  Is the  Building  Used  For  Now  . . . . . . . . . . . . . . . . . . . . . . . . . . .
 9 
ENDNOTES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

APPENDICES

Methodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  A-1

Number  of Hospital  Closuresby  State  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  B-1

Hospital  Closures  byHospital  Name  and  Imcation  . . . . . . . . . . . . . . . . . . . .  C-1
 INTRODUCTION

PURPOSE 
To  describe  the  extent,  characteristics,  and  impact  of hospital  closure  in 1995. 
BACKGROUND 
In the  past,  closure  of general,  acute  care  hospitals  had  generated  public  and 
congressional  concern.  Numerous  questions  had  been  raised  about  the  impact  of hospital 
closure  in the  United  States,  as well as implications  for public  policy.  A number  of 
studies  predicted  that  more  hospitals  would  close  in coming  years. 
In response  to these  concerns,  the  Office  of Inspector  General  released  a report  in May 
1989 describing  the  phenomenon  of hospital  closure  during  1987 in the  United  States. 
We  found  that  the  hospitals  that  closed  were  small  and  their  closing did not  severely 
affect  access  to care.  Many  users  of our  1987 hospital  closure  study  encouraged  us to 
continue  year-by-year  analyses  of the  phenomenon  to detect  differences  in the  rate  of 
hospital  closure,  and  in the  characteristics  and  circumstances  of hospitals  that  close. 
Similar  inspections  of the  phenomenon  of hospital  closure  in 1988 through  1994 showed 
a downward  trend  in the  number  of closures. 
HOSPITAL  CLOSURE 
#  of  Closures  in  U.S.
loo 
so   76 
60-
40-
le 
20   
m 
o-
1eeJ7  -086  1999  *ciao  1991  1992  1993  19L4 
YEAR 
1  The  findings  from  the  1987 through  1994 inspections  were  similar.  The  hospitals  that 
closed  were  small  and  had  low occupancy  rates.  When  the  hospitals  closed,  few patients 
were  affected.  Most  could  get  medical  care  nearby. 
SCOPE 
We  examined  hospitals  that  closed  in calendar  year  1995. 
For  purposes  of this study,  the  following  definitions  were  used. 
Hospital:  A facility  that  provides  general,  short-term,  acute  medical  and  surgical 
inpatient  services. 
Closed  Hospital:  One  that  stopped  providing  general,  short-term,  acute  inpatient 
semices  in  1995.  If a hospital  merged  with  or was sold to another  hospital  but  the 
physical  plant  continued  to provide  inpatient  acute  care,  it was not  considered  a closure. 
If a hospital  both  closed  and  reopened  in 1995, it was not  considered  a closure. 
METHODOIDGY 
To  determine  the  extent  and  impact  of hospital  closure,  we obtained  information  from 
State  licensing  and  certification  agencies,  State  health  planning  agencies,  State  hospital 
associations,  HCFA  data  bases,  officials  associated  with  closed  and  nearby  hospitals,  and 
local  public  officials. 
We  obtained  information  on the  characteristics  of all hospitals  and  those  that  closed  in 
1995 from  the  Hospital  Cost  Report  Information  System  (HCRIS)  maintained  by HCFA. 
Appendix  A describes  our  methodology  in further  detail. 
We  conducted  our  review  in accordance  with the  Quality Standards for Inspections  issued 
by the  Presidents  Council  on Integrity  and  Efficiency. 
2
 FINDINGS

Our  analysis  shows that: 
F	 Thirty-seven  general,  acute  care  hospitals  closedin  1995.  This  istwenty-one  more 
than  in 1994, but  still less than  in any other  year  since we began  this series  of 
reports. 
F  Most  hospitals  that  closed  were  small  and  had  low occupancy  rates. 
F	 Although  residents  of a few communities  had  to travel  greater  distances  for 
hospital  care,  most  had  emergency  and  inpatient  medical  care  available  within  10 
miles  of a closed  hospital. 
EXTENT  AND  CHARACTERETI~  OF  CDSED  HOSPITALS 
How Many Cl&xl 
In  1995, there  were  4,711 general,  short-term,  acute  care  hospitals  in the  United  States 
entered  on HCFAS data  base  as participating  in the  Medicare  program.  Thirty-seven 
hospitals  closed  in  1995 -- 0.8 percent  of all hospitals  nationally. 
Closure  of the  37 general,  acute  care  hospitals  reduced  inpatient  bed  supply  by 3,238 
beds,  or 0.4 percent. 
While  37 hospitals  closed  in 1995, 4 new general,  acute  care  hospitals  opened,  adding  702 
beds  to the  national  supply  of beds.  In addition  to the  new hospital  openings,  1 
previously  closed  hospital  reopened  in 1995, adding  another  23 beds. 
3
 Where Were Z%ey 
The  closed  hospitals  were  located  in 20 States.  Texas  had  the  greatest  number  of 
closures  (11), followed  by Louisiana  (3).  Five States  had  two closures  each,  and  the 
remaining  13 States  had  1 closure  each.  Appendix  B lists the  number  of hospital  closures 
by State.  Appendix  C lists the  closures  by hospital  name  and  location. 
About  the  same  percentage  of rural  and  urban  hospitals  closed  in  1995. 
What  WeretheClosedHqi.tak  Like 
~  Hospitals  that  closed  in 1995 were  small. 
Number  of Closed  Hospitals 
I  I  II 
Number  of Beds  Rural  Urban  Total 
0-30  3  1-
I  1 1 
31-50  7  1-
~ 
1 4 
51-100  2  1-
!
I  7 
101-200  1
!
r 9  1-
201-300  o 
I  I  3  11.J@L 
0 0  II  o 
301> 
Totals  13  IL 
24 
4
 Both  the  rural  and  urban  hospitals  that  closed  in  1995 were  smaller  than  the  average  size 
of rural  and  urban  general,  acute  care  hospitals  nationally. 
HOSPITALS  THAT  CLOSED 
WERE  SMALL 
#  O*  Beds 
260    227.9 
200   
160 
loo 
73a 
60   
o 
RURAL  HOSPITALS  URBAN  HOSPITALS 
_  National  Avg  =  Cloa.ci  Ho=pItal  Avg 
occuDanq  Occupancy  rates  for  closed  rural  and  urban  hospitals  were  lower  than  the 
national  averages.1 
OCCUPANCY  RATES  WERE  LOW 
60%   
60.2% 
60%   
40%   
s3.t3Mb 
30%   
20U   
lo% 
0%   
RURAL  HOSPITALS  URBAN  HOSPITALS 
_  National  Avg  ~  Clo=ed  Hospital  Avg 
5
 Medicare  Utilization:  ~eaverage  Medicare  utilimtion  among  rural  hospitals  that  closed 
was about  the  same  as rural  hospitals  nationally.  The  average  Medicare  utilization 
among  urban  hospitals  that  closed  was higher  than  the  national  average.2 
MEDICARE  UTILIZATION 
70%   
67.-%  6a.1% 
60%    64.e% 
60%   
40%   
30%   
20%   
lo% 
0s   
RURAL  HOSPITALS  URBAN  HOSPITALS 
- National  A- =  Clo=gd  Hoapltal  Avg 
Medicaid  Utilization:  In both  rural  and  urban  areas,  the  average  Medicaid  utilization 
among  hospitals  that  closed  was lower  than  the  national  averages.3 
MEDICAID  UTILIZATION 
20% 
18% 
1e% 
1s.9% 
14% 
11.s% 
1 2% 
1 o% 
e% 
6% 
4% 
2% 
o% 
RURAL  HOSPITALS  URBAN  HOSPITAL= 
- National  A- =  Cloa-cl  Hoapltal  Avg 
6
 IMPACI  OF  HOSPITAL  CIXISURE

In communities  where  hospitals  closed  in 1995, we assessed  the

  number  of patients  affected  by closure  of hospitals,

  availability  of inpatient  care  and  emergency  medical  services,  and

current  use  of closed  hospital  facilities.

E 
How Many PaiikntsWereA#tzted 
For  rural  hospitals  that  closed  in  1995, the  average  daily census  in the  year  prior  to 
closure  was about  10 patients.  The  urban  hospitals  that  closed  had  an average  daily 
census  of 41 patients. 
Rural  Hospitals  Urban  Hospitals 
Average  Number  of Beds  45.6  110.2 
Average  Occupancy  Rate  X 21.8%  X 37.2% 
Average  Number  of Patients  9.9  41.0 
We  analyzed  Medicare  utilization  data  to determine  the  number  of elderly  patients 
affected  by hospital  closure  in 1995,  In rural  hospitals  that  closed,  about  6 Medicare 
patients  were  in the  hospital  on an  average  day in the  year  prior  to closure.  In the  urban 
hospitals  that  closed,  about  22 Medicare  patients  were  in the  hospital  on an  average  day, 
Rural  Hospitals  Urban  Hospitals 
Average  Patient  Census  9.9  41.0 
Average  Medicare  Utilization  Rate  X 58.19?0  X 54.6% 
Average  Number  Medicare  Patients  5.8  22.4 
7
 h@mtientGaredAEnmergenq  Sbices  Avaikdde 
We  assessed  availability  of inpatient  and  emergency  medical  care  in miles  from  a closed 
hospital  to the  nearest  inpatient  and  emergency  facilities. 
Inpatient  Care:  In most  communities  where  a hospital  closed  in 1995, inpatient  hospital 
care  was available  nearby. 
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:+:::.:., :.:,:...: ,... 
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NUMBER  OF  CLOSED 
HOSPITALS 
DISTANCE  Rural  Urban 
Within  3 Miles  1 (8%)  12 (50%) 
4-10 Miles  3 (23%)  12 (50%) 
11-20 Miles  6 (46%)  o 
21-30 Miles  2 (15%)  o 
More  than  30 Miles  1 (8%)  o 
Totals  13 (loo%)  24 (100%) 
Rural Areas:  Residents  in  10 of the  13 rural  communities  (77 percent)  where  a hospital 
closed  could  get  inpatient  hospital  care  within  20 miles  of the  closed  hospital.  Residents 
of Falfurrias,  Texas  had  to travel  36 miles  for fill  service inpatient  hospital  care. 
Urban Areas:  In all 24 urban  communities  where  a hospital  closed  in  1995, residents 
could  get  inpatient  hospital  care  within  10 miles  of the  closed  hospital.  Nineteen  of the 
24 urban  communities  (79 percent)  where  a hospital  closed  could  get  inpatient  care  in 
the  same  town. 
Emer~encv  Services:  When  a hospital  closed,  the  community  lost not  only inpatient  beds, 
but  also 24-hour  emergency  services. 
Rural Areas:  In  12 of the  13 rural  communities  (92 percent)  where  a hospital  closed  in 
1994, emergency  care  facilities  were  available  within  20 miles  of the  closed  hospital. 
Residents  of Karlstad,  Minnesota  had  to travel  28 miles  for 24-hour  emergency  care. 
Urban Areas:  In all 24 urban  communities  where  a hospital  closed  in 1995, emergency 
care  facilities  were  available  within  10 miles  of the  closed  hospital.  Nineteen  of the  24 
urban  communities  (79 percent)  where  a hospital  closed  could  get  emergency  sefices  in 
the  same  town. 
8
 .@@ii:sj&iI @GEN$CiY? iRVhK IiS
.::  !  :@LOS@HQ@n~
NUMBER  OF  CLOSED 
HOSPITALS 
DISTANCE  Rural  Urban 
Within  3 Miles  3 (23%)  12 (50%) 
4-10 Miles  3 (23%)  12 (50%) 
11-20 Miles  6 (46%)  o 
21-30 Miles  1 (8%)  o 
More  than  30 Miles  o  0 
Totals  13 (loo%)  24 (100%)
L 
?f%at Is the ~g  tkd  For NOW 
At  the  time  of our  review,  17 of the  37 closed  hospital  buildings  (46 percent)  were  being 
used  for health-related  services.  For  example: 
Brooks  County  Hospital  in Falfurrias,  Texas  became  an outpatient  clinic and 
emergenq  care  facility. 
Fairbury  Hospital  in Fairbuxy,  Illinois  and  Merryville  General  Hospital  in 
Merryville,  Louisiana  are  now nursing  homes. 
Ludlow  Hospital  in Ludlow,  Massachusetts  and  Caddo  Oaks  Medical  Center  in 
Shreveport,  Louisiana  were  converted  to rehabilitation  hospitals. 
Alamance  Memorial  Hospital  in Burlington,  North  Carolina  is now a home  health 
agency. 
Some  hospital  administrations  and  communities  have  long realized  the  possibility  of their 
hospitals  closing.  They  planned  to use the  closing  as an opportunity  to reassess  and 
improve  community  health  care.  Two hospitals  closed  in 1995 as part  of a plan  to 
upgrade  community  hospital  care:  In Burlington,  North  Carolina,  Alamance  Memorial 
Hospital  and  Alamance  County  Hospital  merged  and  closed  the  existing  two facilities  and 
the  new modern  Alamance  Regional  Medical  Center  opened. 
At the  time  of our  review,  community  officials were  planning  to use  3 of the  remaining 
17 vacant  hospitals  for health-related  semices.  Vencor  Hospital  in Youngtown,  Arizona 
will be  converted  to a nursing  home  and  Family  Hospital  Center  in Amarillo,  Texas  plan 
to re-open.  Menorah  Medical  Center  in Kansas  City, Missouri  will be  used  for  scientific 
research  related  to cancer. 
9
 1.	 Hospital  occupancy  rate  is defined  as the  actual  number  of patient  days divided  by 
the  total  bed  days available.  National  average  occupancy  rate  is defined  as the 
sum  of all hospitals  occupancy  rates,  divided  by the  number  of hospitals. 
2.	 Average  Medicare  utilization  of closed  rural  and  urban  hospitals  is defined  as the 
percent  of Medicare  patient  days compared  to the  total  patient  days for  each 
hospital,  summed  and  divided  by the  number  of hospitals.  National  average 
Medicare  utilization  is the  percent  of Medicare  utilization  of each  hospital, 
summed  and  divided  by the  total  number  of hospitals. 
3.  Medicaid  utilization  is calculated  in the  same  way as Medicare  utilization. 
10
 APPENDIX  A

MErHoDoJmGY 
Extent of  HospitalChure 
To  determine  how many  hospitals  closed  in 1995, we surveyed  State  licensing  and 
certification  agencies,  State  hospital  associations,  and  State  health  planning  agencies.  We 
also compiled  Health  Care  Financing  Administration  (HCFA)  data  on terminated 
providers  in  1995.  When  a closed  hospital  met  the  studys definition  or when  there  were 
questions,  we contacted  ofllcials  associated  with the  closed  hospitals,  officials  associated 
with hospitals  nearest  to the  closed  hospital,  and  local  public  officials. 
To  determine  the  number  of hospitals  in the  United  States,  we used  the  Hospital  Cost 
Report  Information  System  (HCRIS)  maintained  by HCFA.  We  included  only general, 
short-term,  acute  care  hospitals  under  Medicares  Prospective  Payment  System  (PPS)  in 
the  universe.  There  were  4,711 hospitals  listed  on HCRIS  as short-term,  acute  care, 
general  hospitals  for the  eleventh  year  of PPS (PPS  11). 
(laracterikticsof Hospiml Chure 
To  analyze  characteristics  of closed  hospitals,  we used  HCRIS  data.  Cost  reports  were 
not  available  for  2 of the  37 hospitals.  For  the  remaining  35 hospitals,  we used  the  latest 
pre-closure  cost reports.  For  example,  if a hospital  closed  in May  1995 and  its 
accounting  year  was on a January-December  cycle, we used  the  providers  January  1, 
1994 to December  31, 1994 report, 
Impct  of Hmpital Chute 
We  limited  our  impact  analysis  to the  distance  from  a closed  hospital  to the  nearest 
still-operating  hospitals  and  to emergency  services.  We  obtained  data  for our  analysis 
from  interviews  with  the  following  sources. 
  Former  hospital  administrators,  board  members,  and/or  staff of closed  hospitals 
  Hospital  administrators  and/or  staff at the  nearest  hospitals 
  Local  police,  health,  and  government  officials 
  State  health  planning  agencies 
State  certification  and  licensing  agencies 
E 
State  hospital  associations 
b 
A -1
 APPENDIX  B 
3  8 
2 
Arkansas
 II  2  1 
California
 II  2 
Florida
 II  2 
Missouri
 II  2 
1 
North  Carolina
 II  2  1  1 
II 
11  11  1 
Maryland
 1  0  1 
11  II  I 
Michigan
 1  1  0 
I 
Minnesota
 II  1  1  0 
New Jersey

1~ 
II 
Oklahoma
 1 
1 
Pennsylvania
 1  0  I  1 
1 
20 states
 37 closures  13 Rural  I  24 Urban 
B-1
 APPENDIX  C

St. Michael  Hospital  Texarkana  urban 
Nevada  County  Hospital  Prescott  rural 
Vencor  Hospital-Youngtown  Youngtown  Az  urban 
West  Valley  Hospital  Canoga  Park  CA  urban 
Calexico  Hospital  Calexico  CA  rural 
Provenant  Mercy  Medical  Center  Denver  co  urban 
Physicians  Community  Hospital  St. Petersburg  FL  urban 
Polk General  Hospital  Bartow  FL  urban 
Story City Memorial  Hospital  Story  City  IA  rural 
Fairbury  Hospital  Fairbury  IL  rural 
Northwest  Family  Hospital  Gary  IN  urban 
St. Johns  Regional  Health  Center  Salina  Ks  rural 
Caddo  Oaks  Medical  Center  Shreveport  LA  urban 
New Orleans  General  Hospital  New Orleans  LA  urban 
Merryville  General  Hospital  Merryville  LA  rural 
Ludlow Hospital  Ludlow  urban 
Frostburg  Hospital  Frostburg  MD  urban 
Traverse  City Community  Hospital  Traverse  City  MI  rural 
Karlstad  Memorial  Hospital  Karlstad  MN  rural 
AMI Keller  Memorial  Hospital  Fayette  MO  rural 
Menorah  Medical  Center  Kansas  City  MO  urban 
Alamance  County  Hospital  Burlington  NC  urban 
Alamance  Memorial  Hospital  Burlington  NC  urban 
Zurbrugg  Memorial  Hospital  Riverside  NJ  urban 
Thomas  Memorial  Hospital  Thomas  OK  rural 
Thomas  Jefferson  Hospital-Ford  Road  Philadelphia  PA  urban 
Danforth  Hospital  Texas  City  TX  urban 
Goliad  County  Hospital  Goliad  TX  rural 
Westbu~  Hospital  Houston  TX  urban 
Doctors  Hospital  Conroe  TX  urban 
Pasadena  General  Hospital  Pasadena  TX  urban 
Family  Hospital  Center  Amarillo  Tx  urban 
Brooks  County  Hospital  Falfurrias  Tx  rural 
Plaza  Medical  Center-East  Fort  Worth  Tx  urban 
Gilmer  Medical  Center  Gilmer  Tx  rural 
Twin Oaks  Medical  Center  Fort  Worth  TX  urban 
HCA  Medical  Center  of Houston  Houston  Tx  urban 
c-1