EFFECTS OF 1988 RURA'


HOSPITAL CLOSURES 
 ON ACCESS


TO MEDICAL CARE


tlWJCES.lt.r 

'0 

Vd,1a 

OFFICE OF INSPECTOR GENERAL 

OFFICE OF EVALUATION AND INSPECTIONS 

AUGUST 1990 
EFFECTS OF 1988 RURAL
 HOSPITAL CLOSURES ON ACCESS 

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. 

That repo prompte fuer analysis, includig a follow-up study, "Hospita Oosurs: 1988," and 

ths study of the "Efects of 1988 Rur Hospita Oosurs on Accss to Medcal Car." The 

Hospita Closures: 1988" study found that ru hospita tht closed had fewer bed than the 

national averge and thatfe patients ha ben using them in the years pror to closing. The 

average day census of ru 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 

that whether the residents of a communty wher a ru hospita closed believe they have 

serious access problems detered by proximity

l is largely to another hospita. 

In comunties with a nearby hospital (where there is a hospita sti open withn 10 

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. 
In communities without a nearby hospital (where the nearest hospital is now over 10 

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. 

While most have closer hospitals, over hal say they wi travel over 30 mies for 

hospital care, citig better quality or physician refen-al as the reason. 

RECOMMENDATIONS 

Recent legislation gave the Deparent of Health and Huma Servces 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 III.. II ... II II.. II II.. II II.. II II.. II II.. II II.. II II.. II II II II I II II II II II.. 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... II
 II II III 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 III II.. II II.. II II.. II 

SeD pe II II" II II et. II I 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.. 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 . a Nearby Hospital Say 

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 

ru hospitas closed in 1988. 

BACKGROUND 

National Criteri Related to Medical Provir Shortges 

The Deparent of Health and Human Servces (HS) has adssed access to health care in 

rual areas though a number of programs. In parcular, it has developed stadads to 

designate health manpower shortge areas and to qual 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 

distance frm one s residence to a hospita or the tie it 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. 

None of the existig studies have measurd the effects of hospita closur on access to car in 

ru 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 

1987 hospita closurs in the United States. The report prompted furer 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 tye and extent of their services, and to mae 

other changes for improving the quality of car. The Essential Access Community Hospita 

(EACH) Program was authori in the Omnbus Budget Reconcilation Act of 1989. The 

program wil provide grts for up to seven states to crate one or more rual health networks 

to improve access to hospita and other health services for ru residents. The program is 

designed to test the concept of a ru health network in which a new tye of small hospita 

(caled Rur Pr 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 

proposed to provide technical assistance to trubled ru 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 

proximity to another hospital. 

Only 11 percent of residents with a nearby hospita (where there is a hospita stil open

within 10 mies) say they have a serious problem gettig hospital care which they 

attrbute to closure of the hospita. 

Forty percent of residents without a nearby hospita (where the nearst hospita now is

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 signifcantly dependig 

on proxity to another hospita. Twenty of the communities where a ru 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 

In twenty of the communties where ru 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 

inpatient car ar about the same. Th-th percent of al emergency rom visits and 26 

percent of al inpatient hospitations durg 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 

emergency car due to the closurs. These smal prons ar not sursig, given that few 

used the facilty when it was open and tht another hospita is sti opetig neary. 

Where Wil Residents Get Care in the Future? 

Twenty-th 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 of those who would choose to trvel beyond the clsest hospita say they would go 

to another ru hospita. Only nie percnt of househods picke an uran hosita. 

Doe Income, Age or Inrace Affec Whether Housholds Report a Serious 

Problem with Acc? 

The demogrphic chartestics of the respdets wer anyz to detejf ther wer 

dierences in income, age orinmace of those who say thy have a :sous problem with 

access to medcal car. The anSis revealed tht .households-with income below $25,894 

the med income forro ar in 1988, mor fruently rca seo1lprblem gettg 

hospita car than those with higher incoes. 

Comparison of Households with Serious Accss Problems 

by Income Level 

Communities wi a Neay Hospital 

Percent of Housholds w/Seus Proble 

19% 

IS Income above median Income below median 
Analysis also revealed dierences in the age of member of households repog a serious 

access problem. A grter number of households with elderly membe (over age 65) repo a 

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 those with private insurce who report a serious access problem. (Te 

relationship is viy identical to the one depicte in the previous char on age. 

Twenty-th 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 

In 1988, 29 of the 49 ru 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 

proporton (54 percnt) of those who wer hospita 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. 

About the same pron of communty residets use the now-close hospita for 

emergencies (58 pernt) as for gener inpatient ca (50 percnt). Those who bypassed that 

hospita say they did so beause the tratment they nee 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 

mUS travel over 30 mies for general inpatient hospita care, 53 percent say they plan to do 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. 

In most cases, the hospital of choice is a ru one. However, 35 percent of households 

indicatf they would use an urban hospita over a closer ru 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 enacte reently to give the Deparent of Health and Huma Servces 

(HS) the means to assist ru communities to maintan access to medcal car in the face of 

hospital closures. HHS should give higher priority in disttbuting resources for improving 

access to ru 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 

under this progr, a 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 

effect of the program on access to car. Our fidigs 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 

Since both the PHS and HCFAare responsible for adstration of progr for improving 

access to ru health care, those agencies should consult with each other on criteria for and 

award of grants and technical assistace to ru aras. 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


The comments from the Assistant Secretary for Planning Evaluation support our fmal 

recommendations. Prviously, ASPE had also advised HCFA to develop crteria for tagetig 

the Rur Health Car Transition Grants. 

The Assistant Secretary for Health supports the recommendation regarg coordiation 

between the Public Health Servce (PHS) and the Health Car Financing Adminstration. The 

PHS did not concur with a recommendation in the drt 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 the H-ealth Care Financing Administration 
 suggest that our

recommendations were aied 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, 

the best way to maita access to care may be to assist the hospita in modyig 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 

not inadvertently funded over more grant applicants, so that hospitas close to each other are 


remote facilties. Our research suggests that, if funds ar liited grts 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 

DEPARTMENT OF HEALTH AND HUMAN SERVICES CRITERIA 

RELATED TO MEDICAL PROVIDER SHORTAGES 

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: 

located more than 35 mies from other li 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 

the hospita' s service ara ar admtt to other lie hospitas located with a 

35-mie radus of the hospita, or, if larger, within its serce ara; 

the hospita has fewer than 50 bed and the intermedi certes 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 

DEMOGRAPHICS OF RESPONDENTS 

Household Composition 

(20) (29) 

Cluster A Towns 

with nearby 

Cluster B Towns 

without nearby Tota all Towns 

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 

(age 65+) 24% 21% 22% 

Al Adults 

(age 19-64) 30% 21% 25% 

Adults and 11% Elderly only 

Adults and 

Chdrn only 35% 47% 145 42% 

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- 19 years 13% 21% 18% 

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 

Bypassed 

113 

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 

with nearby 

hospital 

Number Percent 

Hospitalizations by 

Incident 

Prior to Closure: 

Used closed 28% 

Bypassed closed 47% used next closest 

Bypassed next 

closest, used one 25% 

beyond 

Subtota Bypassing 72% 

TOTAL (Pior) 110 

After Closure: 

Used closest 72% 

Used next closest 28% 

TOTAL (After) 100% 

Missing 

GRAND TOTAL 

(Por to and Afer 175 

Closure) 

Cluster B Towns 

without nearby Total all Towns 

hospital 

Number Percent Number 

54% 114 

25% 

21% 

46% 151 

155 265 

50% 

50% 

100% 125 

219 394 

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. 

The unverse for this study is people who live in the remag 49 rual towns, and whose 

telephone number preflXes match the closed hospitas . By defig 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 surey be conducted 

phone. Ninety-thee percent of U.S. households have a telephe; in ru areas most 

households have listed numers.6 Prvious 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 35D would prodce an equatons were used to determne that a samle:of 

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 1988. This sample ize does not, however, permt analysis by individual 

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 

The research team recognized that the 49 communities under study ar 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 

is an importt factor and that 10 miles marked the most accurte place for distinguishig the

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 

resembled responses of those with a hospita more than 20 miles away. Strtig at 10 miles 

increased the deviation between strata and deased 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 

clusters to achieve results generazable acss al ru towns where hospitas closed in 1988. 

However, dratic 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 

The researh te 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 

frm the Director of Washigtn State University s Social and Ecnoc 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 

who makes most of the health car decisions, reminded hier 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 

could not be intervewed due to language or hearg diculties

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. 

Chrstopher Hogan. 
 Patterns of Travel for Rural Individuals Hospitalized in New York

State (Washigton, D. C. : National Center for Health Services Research, 1986), and 

Minnesota Deparent of Health. Access to Hospital Services in Rural Minnesota, 

March 1989, and 

LuAnn Aday, Ron Anderson, Grtchen Flemig. Access to Medical Care in the U.


(Chicago, n. : University of Chicago, Center for Health Admistration, 1984), p. 69, and 

S. M. Cageorge, L. L. Roos, and R. Danziger Galbladder Operations: A Populationbased Analysis, Medical Care 
 1981: 19, pp. 510-525.

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 ­