RURA'

EFFECTS OF  1988 
ON ACCESS

HOSPITAL CLOSURES 

TO MEDICAL CARE

tlWJCES.
lt.r 
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Vd,1a 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF EVALUATION AND INSPECTIONS 
AUGUST 1990  EFFECTS OF 1988 
RURAL

ACCESS 
HOSPITAL  CLOSURES ON 
TO MEDICAL CARE

Richard P. Kusserow 
INSPECTOR GENERAL 
OEI-0489-00742  AUGUST 1990
 EXECUTIVE SUMMARY 
PURPOSE 
This inspection was conducte to determe how access to medical care was afected when 
rual hospitas closed in 1988.

BACKGROUND 
In recnt year, the public and Congrss have expressed conce about the closur of hospitas. 
The Ofce of Inspector Genera, Ofce of Evaluation and Insptions (OEI), examed the extent 
and natu of 1987 hospita closurs, releasing its repo "Hospita Closurs: 1987," in May 1989. 
fuer 
That repo prompte  analysis, includig a follow-up study, "Hospita Oosurs: 1988," and 
Rur 
ths study of the "Efects of 1988  Hosrpuita  Oosurs on Accss to Medcal Car." The 
Hospita Closures: 1988" study found that  hospita tht closed had fewer bed than the 
national averge and thatfe patients ha ben using them in the years pror to closing. The 
ru 
day 
average  census of  hospitas tht closed in 1988 was only 11 patients. 
Ths report also provides tiely inormation supporve of Secetar Sulvan s recently set 
objective for the Deparent of Health and Human Serces to improve access to health care. 
FINDINGS 
A surey was conducted of households in communities wher rual hospitas dosed in 1988. 
The surey found that: 
Most residents do not expss a serious problem with acss to mecal car since closur 
the hospita in their communty. However, close exaation of the surey results reveals 
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that whether the residents of a communty wher a  hospita closed believe they have 
l is largely 
serious access problems  to another hospita. 
detered by  proximity
a nearby hospital (where there is a hospita sti open withn 10 
In comunties  with 
miles): 
Only 11 percent of residents express a serious problem gettig hospita care 
which they attbute to closure of the hospital. 
74 percent of residents say they want the hospital reopened. 
28 percent of those who received inpatient or emergency care in a hospital since 
mid-1984 actually used the now-closed hospital. 
23 percent of households, most citing higher quality of care, now would bypass 
the closest hospital for one more than ten mies away.  a nearby hospital (where the nearest hospital is now over 10 
In communities  without 
mies away):

40 percent of residents say they have a serious problem 
gettg hospita care due 
to closure of the hospita. 
94 percent of residents say they want the hospital reopened. 
54 percent of those who actualy received inpatient or emergency care in a 
hospital since mid-1984 used the now-closed hospita. Those who bypassed that 
hospital say the tratment they neeed was not provided there, or their 
physicians referrd them to other facilties. 
wi 
While most have closer hospitals, over hal say they  travel over 30 mies for 
hospital care, citig better quality or physician refen-al as the reason. 
RECOMMENDATIONS 
Recent legislation gave the Deparent of  Huma Servces 
Health and  responsibilty for 
several new program. The progrs provide assistace to rual communities for maitaing 
access to medcal care in the face of hospita closurs. Our reommendations focus on the 
programs in The Health Care Financing Admnistrtion (HCFA) and the Public Health Service 
(PHS). 
The Admstrator of HCFA should develop precise crteria for tagetig Rural Health Car 
Transition Grants. In selectig grantees under ths program, a higher priority should be given 
to remote hospitals. Furer, HCFA should assur that the ftrst seven states chosen to 
parcipate in the Essential Access Community Hospita (EACH) progr wi adequately test 
the effect of the program on access to care. Our fmdings indicate that to do so, remote 
hospitas must be included among the 
initial sites. 
The PHS and HCFA should consult with each other on criteria for and award of grants and 
technical assistace in the simlar programs which each agency admnisters. 
COMMENTS 
The draft report was circulated for comment to the Assistant Secretar for Health, the 
Admstrator of HCFA, the Assistant Secretar for Planning and Evaluation (ASPE), and the 
Assistat Secretar for Public Affairs in April 1990. The comments from ASPE support the 
fmal recommendations. Based on comments from HCFA and PHS, we clared the wording 
of the recommendations and deleted a recommendation regardig placement of National 
Health Service Corps members. A number of technical suggestions were also incorporated 
into the report.
 .... ................. ......-._-.... ............. .... .....................  ..........-............ .....  ..... ................ .. ......... .... ............. ........... ....  .....................-....................-........................... ......... ........... . ......
............... ............. .......... 
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION. .... .... ........ ...........  ...... ............... ...... .... ........ ... 1
Pu rpose 
II.. II II.. II ... II II.. II II.. II II II II IIII.. II II II II IIII.. II ... II II.. II II.. II II.. II II.. II II.. II II.. II II.. II II II III I II III I III I.. II II.. II II.. II II II.. II II.. II II.. II II IIII.. .... 1
Backg ra u nd II...... II II.. II ... II II.. II... IIII I
I IIII II.. II II.. II II.. II II.. II ... II II.. II... II II.. II II.. II II.. II II.. II II.. II II II II... II II.. II II II IIII II.. II II.. II II.. II 
SeD pe II II" II II et. III I II III I II III I III I.. II II II.. II.. II II II.. II.. II II.. II II.. II II.. II II.. II II...... IIII.
. II II.... ... II.. II II.. II II.. II II.. II II.. II II II.. II II.. II II.. II II.. II... II 2
Meth OdD logy II.. II II.. II II.. II II.. II II.. II II.. II II.. II II.. II II.. II II.. II II.. II ... II"'. II II.. II II.. II ... II II.. II II.. II II.. II II.. II II.. II II II.. II II II IIII II IIII IIII... 3
FI N DI NGS. .11.... II. II...........  ..11.... 4
Proximity is the Key Factor 
.....................--....................-................................... 4
Most With  Nearby Hospital Say 
. a 
They Do Not Have Serious Access Problems- ...-............... ................. ..... 5
Many Without a Nearby Hospital 
Express Serious Access Probl-ems ..".."..118.."..-.".."......"...".............."."". 7
R ECO M M EN D A TIO NS ...........  ........ ... 10
COMMENTS ON DRAFT REP' ORT ................................

APPENDIX A 
Department of Health oand Human Services 
Criteria Related to Medical ProviderShortges........................._.....

APPENDIX B

Demographics of -Respondents .............  ............... ................................ B

APPENDIX C 
Methodology and Sample Selection .............................................................. C-1
EN D NOTES ......... ... ... .......... ............ ......  .... D
 INTRODUCTION

PURPOSE 
This inspection was conducted to determine how access to medcal care was afected when 
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hospitas closed in 1988. 
BACKGROUND 
National Criteri Related to Medical Provir Shortges 
adssed 
The Deparent of Health and Human Servces (HS) has  access to health care in 
rual areas though a number of programs. In parcular, it has developed stadads to 
qual 
designate health manpower shortge areas and to  hospitas as sole community 
providers for enhanced Medcar reimburement. Although these measurs presume a 
generaly accepte stadad, they do not explicitly state what constitutes adequate access to 
medcal car. (The crteria related to health provider shortges appear in appendi A. 
These crteria do not consider factors which var from one individual to another, such as 
tie it 
distance frm one s residence to a hospita or the  taes to travel the distace. 
Judgments regardig the adequacy of access to medcal servces must consider factos such as 
individuals ' actual distace from and their ease of obtaing car. Sureys have been 
conducted by HHS and others to gather ths individual and subjective information from 
samples of the U.s. population. 
Surveys on Access 
Researchers, in measurg access to medcal car, have examined hospita discharge and 
fmancial records, interviewed health experts, and sureyed the population. These studies have 
identied factors which afect individuals ' access to care, includig mobilty, existence of a 
personal physician, severity of ilness, income, and insurance coverage. 
rNuon e of the existig studies have measurd the effects of hospita closur on access to car in 
communities. Nor have prior national studies determined whether rual communty 
residents themselves judge their access to care to be adequate. 
Studies of Hospital Closure 
In Apri1989, the Offce of Inspector General released a report on the extent and natu of 
furer 
1987 hospita closurs in the United States. The report prompted  analysis of the 
hospita closure phenomenon. Follow-up studies (planned or in process) include: 
Hospital Closure: 1988" and "Hospital Closure: 1989;

Access to Care in Urban Aras Where Hospitals Have Closed;  Hil Bunon Hospitas' Community Servce Obligations; 
The Effects of Hospita Mergers;" and 
ths study on the "Effects of 1988 Rural Hospita Closurs on Access to Medcal Car. 
Recent Legislation Related to Hospital Care in Rural Areas 
In 1987, Congrss passed legislation authorizing the Health Care Financing Admnistration 
(HCFA) to establish the Rural Health Care Trasition Grants Program. The program awards 
grants to smal rual hospitas to modfy the  extent of their services, and to mae 
tye and 
other changes for improving the quality of car. The Essential Access Community Hospita 
authori 
(EACH) Program was  in the Omnbus Budget Reconcilation Act of 1989. The 
program wil provide grts for up to seven states to 
crate roune  or more rual health networks 
to improve access to hospita and other health services for  residents. The program is 
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designed to tePst thre c oncept of a  health network in which a new tye of small hospita 
Rur 
(caled  Car Hospita, RPCH) provides emergency and 
temporar car, and 
trsfers stabilze patits to a larger, centr hospita (termed ID EACH). 
Furer, the Admstration s proposed 1991 Budget fuds the Offce of Rural Health Policy 
$4 miion, an increase of $1 millon over the previous year. These additional funds 
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proposed to provide technical assistance to trubled  hospitas. The Offce wil be 
developing a plan for providig assistace. 
SCOPE 
The unverse for ths study was households in communities where 
rual hospitas closed in 
1988. Intervews were conducted with people who lived nea the closed hospita, and who 
had reside in these communities at least 5 year. 
Residents were asked about their access to inpatient and emergency care before and after the 
hospital closed. Respondents provided information on eac instance of inpatient 
hospitalation or emergency care (up to a maximm of five) durg the previous five years 
for up to seven members of the household. (See appendi B for a descrption of the 
respondents and their hospitaizations. 
Inpatient hospita care wasdefmed as treatment for general conditions such as appendicitis or 
pneumonia, rather than specialty care. Emergency car was defined as tratment for an 
accident or serious ilness. Since hospita closur, the source for emergency care could be a 
provider other than a hospita. In this repon the term "medcal car" refers to these two tyes
of care: inpatient and emergency.  METHODOLOGY 
A stratified radom sample was pulled from phone ditories of 49 communities where 
hospitas closed in 1988. Based on the presumption that access to care vared accordg to 
proximity to an open hospita, the sample was stratied into two groups or "clusters. " Cluster 
A consisted of communities that had a second hospita in town or with 10 miles. Cluster B 
contaned communities where the nearst hospital is now (since the closure) over 10 miles 
away. 
The Social and Economic Sciences Research Center of Washigton State University 
conducted telephone interviews in September 1989. The response rate was 69 percent. 
(appendi C contans a detaed descrption of the study method. 
In ths report, communties that sti have a hospita with 10 mies since the closur 
tenned "communities with a nearby hospita. " The converse, "communties without a nearby 
hospita," refers to those where the only hospita within 10 mies was the one that closed  FINDINGS

This surey of households in communities where rual hospitas closed in 1988 found that: 
Most residents do not express a serious problem with access to medcal car since 
closur of the hospital in their community. Whether closure causes serious access 
problems l is largely determned by  to another hospital. 
proximity 
a nearby hospita (where there is a hospita stil open
Only 11 percent of residents  with 
within 10 mies) say they have a serious problem gettig hospital care which they 
attrbute to closure of the hospita. 
a nearby hospita (where the nearst hospita now is
Forty percent of residents  without 
over 10 mies away) say they have a serious problem gettng hospita care and attbute 
it to closure of the hospital. 
PROXIMITY IS THE KEY FACTOR 
The impact of rual hospital closures on access to medcal car diers sriugn ifcantly dependig 
on proxity to another hospita. Twenty of the communities where a  hospita closed in 
1988 have another hospita with 10 mies. In th remaig communities (29), the hospita 
that closed was the only one within 10 mies. Only 11 percent of those with a nearby hospita 
report a serious problem gettg medcal care due to the closure, whie 40 percent of those 
without a nearby hospita say they have a serious access problem due to the closur. Analysis 
of the data at the conclusion of the study revealed tht lOumies marked the most accurte 
place for distiguishig the two groups. 
It is importt to keep in perspective that most of the residents of communities where 
hospitals closed in 1988 lived in those communities that have another hospital with 10 
miles. In addtion, the rual hospitals that closed were smal. The "Hospita Closure: 1988" 
study found that the hospitas that closed averaged 40.2 bed, which is hal the national 
average for rual hospitas. The average occupancy rates for the closed facilties (26. 
percent) were also below the national average. In fact, the average day census of rual 
hospitas that closed in 1988 was only 11 patients. 
This report presents findings for the two sample strata separately so that the experiences of 
those with serious access problems ar not obscured by the grater number who had no such 
problems.  MOST WITH A NEARBY HOSPITAL SAY THEY DO NOT HAVE SERIOUS 
ACCESS PROBLEMS 
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In twenty of the communties where  hospitas closed in 1988, ther is another hospita 
with 10 miles. A smal proporton of residents in these communties actualy use the 
now-closed hospitas. Few now report havig a serious prblem gettg medcal car. 
How Do Opinions on ReOpening Compare to Prior Use? 
Although 74 percent of households in these communties say they want the hospita reopened 
only hal say they would use it. In fact, only 28 percnt of al those who used a hospita for 
emergency or inpatient car between mid-1984 and the tie the hospita closed actualy used 
the now-
closed facilty. 
Should Hospital Be Reopened?  Did You Use Hospital 
Would You Use It?  Before It Closed? 
Househods  Hopitalizions 
100  100 
28% 
. Wa Ha To  &1 Wold Us  DI U8 
The proportons of those who used the now-closed facilty for emergencies and for genera 
th 
inpatient car ar about the same. Th- percent of al emergency rom visits and 26 
hospitations durg 
percent of al inpatient  the study period were in the now-closed 
hospita. 
Those who bypassed the hospita prior to closur say they did so because the tratment they 
neeed was not avaiable at that facilty, or because their physicians referr them elsewhere.  How Many Have a Serious Problem with Acce? 
Only 11 peent of residnts of communties with a neary hospita expss a serious problem 
gettg gener inpatient hospita ca, .and 13 pent have a serous prblem gettg 
prons  sursig, 
emergency car due to the closurs. These smal  ar not  given that few 
used the facilty when it was open and  sti opetig neary. 
tht another hospita is 
Where Wil Residents Get Care in the Future? 
th 
Twenty- percent of households, most citig higher quaty of car, would bypass the 
closest hospita for one more than ten mies away. 
For emergency car, 19 pent of residents woul bypass the neast hospita. 
Alost al orfu th ose who would choose to trvel beyond the clsest hospita say they would go 
to another  hospita. Only nie percnt of househods picke an uran hosita. 
Inrace 
Doe Income, Age or  Affec Whether Housholds Report a Serious 
Acc? 
Problem with 
anyz  detejf 
The demogrphic chartestics of the respdets wer  to  ther wer 
dierences in income, age orinmace of those who say thy have a :sous problem with 
access to medcal car. The aanrS is revealed tht .householdsr-wciath  income below $25,894 
med  forro 
the  income  in 1988,  mor fruently  seo1lprblem gettg 
hospita car than those with higher incoes. 
Comparison of Households with Serious Accss Problems 
by Income Level 
wi a Neay 
Communities  Hospital 
Percent of Housholds w/Seus Proble 
19% 
IS Income above median  Income below median  repog a 
Analysis also revealed dierences in the age of member of households  serious 
access problem. A  households with elderly membe (over age 65) repo a 
grter number of 
serious problem gettg hospita car than households without elderly members. 
Comparison of Households with Serious Access Problems 
by Age of Members 
Communities with a Nearby Hospitl 
Percent of Housholds w/Serious Problem 
23% 
With No Elderl BJ With Elder 
Analysis of insurce coverge revealed a signcant dierence between households with 
Medcar and tvhosiey wi th private insurce who report a serious access problem. (Te 
relationsthhip i s  identical to the one depicte in the previous char on age. 
Twenty- percent of households with Medcar report a serious prblem gettg hospita 
car compar to only 9 pent with private insurce. The saple did not conta a 
sufcient number of households with Medcaid or with no insurce to include them in the 
comparsons. 
MANY WITHOUT A NEARBY HOSPITAL EXPRESS SERIOUS ACCESS 
PROBLEMS 
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In 1988, 29 of the 49  hospitas that closed wer the only ones with 10 miles. In these 
communties, a signcant proporon of the residents had use the now-closed hospitas. 
Since closur, 40 percent repor a serious problem gettg medcal car and attbute that to 
the hospita closur.  How Do Opinions on Reopening Compare to Prior Use? 
Vlraly al 
residents (94 peent) of communties without a neary hospita want the hospita 
to reopen. Seventy percent indicat they would use it if reened In fact, a sizable 
hospita 
proporton (54 percnt) of those who wer  or reeived emerency car in 
hospita between mid-1984 and the tie the hospita closed actualy use the facty. 
Should Hospital Be Reopened?  Did You Use Hospitl 
Would You Use It?  Before It Closed? 
Households  Hospitizions 
100  100 
94% 
54% 
. W8 Hc To  rs Wold UI  IQ Dicit. 
pron 
About the same  of communty residets use the now-close hospita for 
ca 
emergencies (58 pernt) as for gener inpatient  (50 percnt). Those who bypassed that 
nee 
hospita say they did so beause the tratment they  was not provided there, or their 
physicians referr them to other facties. 
How Many Have a Serious Problem with Accs? 
For pernt of residents in communties without a nearby hospita expss a serious problem 
gettg genera inpatient hospita car, and attbute the prblem to closur of the hospita. 
Vlraly 
the same proporton (42 percent) report a serious problem gettg emergency car 
due to the closur. It was anticipated that more people would be seriously concerned about 
access for emergency car than for general inpatient car followig the hospita closurs. In 
many of these communities, emergency car is sti avaiable in close proxiity since the 
hospita closure. The avaiabilty of emergency providers may have mitigated potential 
problems with access to emergency care for many residents.  Where Wil Residents Get Care in the Future? 
Over hal of residents of communties that no longer have a nearby hospita say they 
wil go to 
a hospita over 30 miles away for futue car. Almost al have a closer hospita; the ' 'Hospita 
Closure: 1988" inspection found that in only four towns where a rual hospita closed is the 
next hospita over 30 miles away.

Whe 
only six percent of the households sampled in communties without a nearby hospita 
travel over 30 mies for general inpatient hospita care, 53 percent say they plan to do 
mUS  so. 
The most often cited reasons for not using the closest hospita were qualty of care (42 
percent) and physician referr (20 percent). Asked why they would choose the hospitas they 
named, respondents commente: 
Because I trst them, they ar more up to date, mor modern. 
Doctors are more qualed. 
Better hospita--update facilties--most doctors use it. 
For emergency car, 36 percent of residents choose to travel over 30 mies. 
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In most cases, the hospital of choice is a  one. However, 35 percent of households 
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indicatf they would use an urban hospita over a closer 
one. 
Does Income, Age or Type of Inurance Affect Whether Households Report a 
Serious Problem with Access? 
In communities without a nearby hospita, the proporton of households reportg a serious 
problem gettg hospita care does not var with: 
income above or below the medan; 
private insurance or Medcare; or 
presence or absence of elderly members in the household.  RECOMMENDATIONS

Legislation has been enacrteu re ently to give the Deparent of Health and Huma Servces 
(HS) the means to assist  communities to maintan access to medcal car in the face of 
hospital closures. HHS should give higher priority in disttbuting resources for improving 
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access to  medical care to communities whose residents, following closur of the hospita, 
are most likely to have a serious access problem. 
Health Care Financing Administratin 
The HCFA admsters Rural Health Care Trasition Grants and wil manage the Essential 
Access Community Hospital Prgram 
Rural Health Care Transition Grants: The Admstrator of HCFA should develop precise 
guidelines for tageting the Rural Health Car Transition Grants. The 
guidelies should 
discuss the issue of proxmntyof applicant hospitas to other 
hospitals. In selecting grantees 
progr, a 
under this  higher priority should be given to remote hospitas. 
Essential Access Community Hospital (EACH): The Admnistrator of HCFA should assur 
that the fIrst seven states chosen to parcipate in the EACH program will adequately test the 
fidigs 
effect of the program on access to car. Our  indicate that to test access remote 
hospitals must be included among the intial sites. Furer, program regulations shoud 
require states to specifIcaly address the access nes of elderly and low income residents in 
the required state 
rual health plan. 
Coordination of PHS and HCFA Responsibiliti 
progr 
Since both the PHS and HCFAare responsible for adstration of  for improving 
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access to  health care, those agencies should consult with each other on criteria for and 
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aras. 
award of grants and technical assistace to  Specifcally, PHS and HCFA should 
coordiate their activities regardig grants and technical assistace from the OffIce of Rural 
Health Policy, the Rural Health Care Transition Grts program, and the EACH program 
given that funds ar appropriated for all of these.  COMMENTS ON DRAFT REPORT

support our fmal 
The comments from the  Assistant Secretary for Planning  Evaluation 
tagetig 
recommendations. Prviously, ASPE had also advised HCFA to develop crteria for 
the Rur Health Car Transition Grants. 
regarg 
supports the recommendation  coordiation 
The  Assistant Secretary for Health 
between the Public Health Servce (PHS) and the Health Car Financing Adminstration. The 
drt 
PHS did not concur with a recommendation in the  report regardig the National Health 
Servce Corps (NHSC). That recommendation caled for a modcation in the crteri for 
placement of NHSC professionals to faciltate their placement in communities that no longer 
have a hospita. PHS objected to ths because, "the curnt NHSC policy is to identiy those 
designate Health Mapower Shortge Areas that have the gratest nee..the present crteria 
do not taget assignents only for communities that have hospita. 
We agr. We delete th recommendation frm the fial report since NHSC placements  can 
be made in areas without hospitas, and the exitig NHC policies curntly provide for 
placement of Corps personnel in aras that have the gratest nee. 
The comments frm  suggest that our
the  H-ealth Care Financing Administration 

aied 
recommendations were  at keeping faing hospitas open, and that assistace should be 
confed to hospitas more than a specifed distace from another hospita. We did not intend 
that HCFA protect all faig hospitas from closur. As the transition grt progr suggests, 
maita  modyig 
the best way to  access to care may be to assist the hospita in  its service 
offerigs to better meet community nees. 
On the second point, our draf did not intend to suggest that HCFA' 
s assistace be  confined
hospitas more than 10 miles from another hospita, or that HCFA adopt 10 miles as the 
absolute crterion for decidig which communties should be assisted. We do, however 
recommend that HCFA consider the proxiity of hospitas to each other when evaluatig 
inadvertently funded over more
not 
grant applicants, so that hospitas close to each other are 
 ar liited grts 
remote facilties. Our research suggests that, if funds  should be tageted on 
hospitals distat from other hospitas. HCFA suggests a greater distace -- 35 miles. We 
would defer to HCFA on specifc mieage stadads. In order to clary our recommendations, 
we removed the reference to 10 miles and substitute the tenn "remote. 
In regard to HCFA's general comments, we made the changes which update our inonnation 
where necessar.
 APPENDIX A 
AND HUMAN SERVICES CRITERIA 
DEPARTMENT  OF  HEALTH 
MEDICAL PROVIDER SHORTAGES 
RELATED  TO 
Crteria for designation of a health manpower shortge ara: 
population to physician ratio is at least 3,500:1; or 
population to physician ratio is between 3,00:1 and 3,500:1, plus unusualy high needs 
or insuffcient capacity, as defied by specific fonnulas for such indicators as number of
birs, 
deaths, and office visits per physician; or 
prima medcal care manpower in contiguous aras is overutiliz; 
excessively distat; 
or inaccessible to the population, due to signicant differences in demogrphic or 
socio-economic chacteristics, or lack of economic access (Le., contiguous areas do not 
accept Medcaid or provide servces for those unable to pay). 
HCFA classifes a sole community hospita ifit is located in a rual are  and meets one of the 
following conditions: 
li 
located more than 35 mies from other  hospitas; 
located between 25 and 35 mies from other lie hospitas ana meets one of the 
following crteria: 
no more than 25 percent of residents who become hospita inpatients or no more 
than 25 percent of the Medcar beneficies who-become hospita inpatients in 
admtt 
the hospita' s service ara ar  to other lie hospitas located with a 
35-mie radus of the hospita, or, if larger, within its serce ara; 
intermedi certes 
the hospita has fewer than 50 bed and the  that the 
hospita would have met the criteria in the pargrph imedately 
above ths one 
were it not for the fact that some beneficiares or residents were forced to seek 
care outside the servce ara due to the unavailabilty of necessar specialty 
services at the community 
hospita; or 
due to local topography or periods of prolonged severe weather conditions, other 
like hospitals are inaccessible for at least one month out of each year. 
located between 15 and 25 miles from other lie hospitals but because of local 
topography or periods of prolonged severe weather conditions, other 
lie hospitas are 
inaccessible for at least 30 days in each 2 out of 3 yrs. 5  APPENDIX B 
RESPONDENTS 
DEMOGRAPHICS  OF 
Household Composition 
(20)  (29) 
Cluster A Towns  Cluster B Towns 
Tota all Towns 
with nearby  without nearby 
hospital  hospital 
Number  Percent  Number  Percent  Number  Percent 
Households  143  40%  210  60%  353 
Members  400  37%  671  63%  1071 
Sex 
Male  196  49%  331  50%  527  49% 
Female  204  51%  337  50%  541  51% 
Missing 
Households by Age 
of Members 
TOTAL  143  210  353 
Al Elderly 
24%  21%  22% 
(age 65+) 
Al Adults 
30%  21%  25% 
(age 19-64) 
Adults and 
11% 
Elderly only 
Adults and 
35%  47%  145  42% 
Chdrn 
only 
Al ages 
Other 
Unkown 
B 
 Household Description 
Cluster A Towns  Cluster B Towns 
with nearby  without nearby  Total all Towns 
hospita  hospital 
Number  Percent  Number  Percent  Number  Percent 
Type of Insurance 
(Head of Household) 
Prvate  64%  123  59%  213  61% 
Medicar  26%  20%  22% 
Medcaid 
Other Govt. 
Unired 
11% 
Other 
Don 
t Know/ 
Missing 
TOTAL  143  210  353 
Years lived in Town 
9 year  12%  14%  13% 
10- 13%  21%  18% 
19 years 
20-49 year  45%  43%  154  44% 
50+ years  30%  21%  25% 
TOTAL  143  210  353 
Household Income 
0-$5, 
$5,000-10,000  15%  12% 
$10,000-15,000  19%  14%  16% 
$15,00025,000  17%  26%  23% 
$25,000-50,000  39%  31%  107  34% 
$50,000+ 
TOTAL  125  189  314 
Missing  Hospital izations

Cluster A Towns  Cluster B Towns 
with nearby  without nearby  Total all Towns 
hospital  hospital 
Number  Number  Number 
Hospitalizations by 
Household"''' 
Pror to Cosure: 
At Closed 
113 
Bypassed 
Subtota  111  195 
Afr Cosur:

TOTAL  134  156  290 
Households in which 
no one was  120
hospitaze 
** Household counts tota more than 353 because households are counted more than once when
members were hospitazed at dierent facilties or at dierent periods of time.  Hospitalizations 
Cluster A Towns  Cluster B Towns 
with nearby  without nearby  Total all Towns 
hospital  hospital 
Number  Percent  Number  Percent  Number 
Hospitalizations by 
Incident 
Prior to Closure: 
Used closed  28%  54%  114 
Bypassed closed 
47% 25% 
used next closest 
Bypassed next 
closest, used one  25%  21% 
beyond 
Subtota Bypassing  72%  46%  151 
TOTAL (Pior)  110  155  265 
After Closure: 
Used closest  72%  50% 
Used next closest  28%  50% 
TOTAL (After)  100%  100%  125 
Missing 
GRAND TOTAL 
(Por to and Afer  175  219  394 
Closure) 
B  Hospitalizations 
Cluster A Towns  Cluster B Towns 
with nearby  without nearby  Tota all Towns 
hospital  hospital 
Number  Percent  Number  Percent  Number 
Type of Care 
Received 
Inpatient  122  70%  153  70%  275 
Emergency  30%  30%  118 
Missing 
TOTAL  175  219  394 
B 
 APPENDIX C 
METHODOLOGY AND SAMPLE SELECTION 
This inspection was designed to determe how access to medical care was afecte in rual 
communities where hospitas closed in 1988. A strtified random sample of the residents of 
these communities was sureyed by telephone durng September 1989. 
Size and Source of Sample 
The Inspector General' s report entitled "Hospita Closure: 1988" identifies 50 rual towns 
where hospitas closed in 1988. In one of those towns the hospita reopened 5 months later. 
remag 
The unverse for this study is people who live in the  49 rual towns, and whose 
defig 
telephone number preflXes match the closed hospitas . By  the universe in ths way, 
we assured that households included in the samle ar (a) near the closed hospitas and, 
therefore, (b) most liely to have been afected by the closure of the hospitas. 
The complexity of the sequencig of questions reuied that the sureyr bue  conducted 
phone. Ninety-thee percent of U.S. households have a telephe; in  areas most 
6 Prvious 
households have listed numers. studies have foundthat-households with phones 
differ demogrphicaly frm those wiout phones. The potetial bias intruce by these 
differences was considered acceptable for this-stuy. 
Stadad statistial equatons were used to determne that a samle:of  35D  would prodce an
estimate with 5 percent of the tre value at the 95 pecent confidence level, using binar 
questions. A sample of 350 permts generaliztion of fidigs across rual communties where 
hospitas closed in  ize does not, however, permt analysis by individual 
1988. This sample 
community. 
A response rate of 60 percent was considered acceptable and acevable. Given this 
expectation, a candidate pool of 600 names was drwn to obtain at least 350 complete 
intervews. 
Stratification: Procedures and Effects 
ar 
The research team recognized that the 49 communities under study  diverse, and that a bias 
might be introduced into the fmdings if importt dierences were not identied and 
controlled for. A major factor was presumed to be proximty to a still-operatig hospita. To 
assure that we could measure the impact of this factor, and control for it, the 49 towns in the 
study were divided into two groups, or "clusters." Towns with a sti-open hospital in town or 
within 10 miles were placed in Cluster A. Towns more than 10 mies from a sti-open 
hospital were placed in Cluster B. Clusters A and B contaned 20 and 29 towns respectively. 
C - 1
 Analysis of the data at the conclusion of the study revealed that proxity to another hospita 
an importt factor and that 10 miles marked the most accurte place for distinguishig the
is 
clusters. Analysis entaed dividig the sample into 3 groups (those with hospitas with 0
miles, 11-20 miles, and grater than 20 miles) and comparg the responses. Responses from 
the midde group, those with a hospita between 11 and 20 mies away, more closely 
Strtig 
resembled responses of those with a hospita more than 20 miles away.  at 10 miles 
deased 
increased the deviation between strata and  the deviation withn strta, thus 
maximizig the value of the stratified samplig. 
The origial intent was to appropriately weight and combine the data collected from the two 
ru 
clusters to achieve results generazable acss al  towns where hospitas closed in 1988. 
dratic 
However,  dierences were found between the clusters for nearly al tabulations. 
Ths fmal report is strctued around those dierences; fidigs for Cluster A and Cluster B 
are presente separately thughout. 
At a confdence level of 95 percent, estiates for Cluster A are with 8 percent of the tre 
value, and for Cluster B with 7 percent, for binar questions where al respondents in the 
cluster answered. 
Pullng the Sample 
Telephone diectories were collected from al 49 towns. The diectories were separate into 
Cluster A and Cluster B. 
Telephone diectories dier widely in number and size of pages, number of columns per page, 
prit size, and number of names per page. If these dierences are not accommodted, names 
in denser phone books will have a lower probabilty of selection than those in books with 
fewer names per page. In order to overcome ths lack of stadazation, each town was 
assigned a weight based on its population relative to other communities in the cluster. With 
ths adjustment, every name in the cluster had an equal probabilty of selection. 
A Statistical Analysis System (SAS) program was used to generate a set of radom numbers. 
These numbers were used to specify a telephone ditory page and a position on the page for 
each of the 600 names to be drwn into the candidate pool. The research team--sta of the 
Offce of Evaluation and Inspections (OEI) in Atlanta--puled the sample. 
C- 2
 Out of the origial 60 names in the pool, 89 were found to be inappropriate (or impossible) 
to include in the study: 
were businesses (the study unverse was households) 
individuals had lived in the town less than 5 year 
(the study reuid 5 years' residence) 
had disconnected phones with no forwardig number 
and could not be reached for intervew 
The fmal candidate pool, then, contaed 511 names, representig households in residence for 
at least 5 years in rual towns where hospitas closed in 1988. 
Data Collection 
te 
The researh  prepared and sent a notication lettr to -expla the study and encourage 
coperation with the telephone intervew to follow in 1 to 2 weeks. 
The OEI sta developed a telephone intervew instrent with tehncal advice and assistace 
Ecnoc 
frm the Director of Washigtn State University s Social and  Sciences Researh 
Center (SESRC). 
The SESRC, a comprehensive surey organon, conducted th telephone intervews in 
September 1989. At least four attmpts at varous ties of the day were mad to contat al 
names in the candidae pool. On contact, interewer idenrledthe adult in the household 
hier 
who makes most of the health car decisions, reminded  of the purose of the study, 
and proceeed though the questionnaie. Inteewers use a computer-assisted telephone 
intervewig system to collect and enter data. 
Response Rate 
Of the 511 households appropriately included in the sample: 
refused to be intervewed 
could not be reached by phone 
hearg diculties
intervewed due to language or 
could not  be 
The remainig 353 households were intervewed, producing a surey response rate of 69 
percent  , "

ENDNOTES

Respondents defined "serious problem" for themselves; the interviewers did not provide 
any defmition. Respondents were asked if gettg hospital car is a serious problem, a mid 
problem or not a problem for them or members of the household. The same question was 
posed for getting emergency car. Approximately 20 percent of respondents in both clusters, 
regardless of demogrphic characteristics, reported havig a mid problem gettig either 
emergency or general hospita car. 
Patterns of Travel for Rural Individuals Hospitalized in New York
Chrstopher Hogan. 

(Washigton, D. C. : National Center for Health Services Research, 1986), and 
State 
Minnesota Deparent of  Access to Hospital Services in Rural Minnesota, 
Health. 
March 1989, and 
LuAnn Aday, Ron Anderson, 
Grtchen Flemig.  Access to Medical Care in the U.

: University of Chicago, Center for Health Admistration, 1984), p. 69, and 
(Chicago, n.
S. M. Cageorge, L. L. Roos, and R. Danziger Galbladder Operations: A Population-
based Analysis,  1981: 19, pp. 510-525.
Medical Care 

The median income for rual areas in 1988 was $25, 894 accordig to:  Current 
Money Income and Povert Status in U. S. - 1988," Series P-60, No. 166.
Population Report, 

Vol. 45, No. 223, November 17, 1980, Appendi A, pp. 76001-76003.
Federal Register, 

Code of Federal Regulations  42, Ch.  (10- 89 Edtion), section 412.92. 
6ne Robert Wood Johnson Foundation Access to Health Care in the United States: 
(Pnceton, N. J. : The Robert
Results of a  1986  Survey,  Special Report, Number  Two/1987 
Wood Johnson Foundation). 
D