SGEM Xtra: This is My Life – Centralization of Rural Emergency Healthcare

Date: April 4th, 2023 Reference: Vaughan and Browne. Reconfiguring emergency and acute services: time to pause and reflect. BMJ Qual Saf. 2023 Apr Guest Skeptics: Dr. Louella Vaugh is an internist practising as a hospitalist physician at an academic centre in London, UK with a special interest in smaller, rural and remote healthcare. Her main job is working for a think tank. John Brown PhD is a Professor of Health Services Research in Ireland who has been studying rural healthcare issues since 2012. This is an SGEM Xtra episode. There have been many “temporary” rural emergency department closures during the past last year. In Ontario alone there have been approximately 160 emergency departments (ED) temporarily closed since the beginning of 2022. This is something that has only happened once since 2006 (Ottawa Citizen March 28, 2023) The study referred to in the editorial looks at the experience in Denmark with a reconfiguration of their emergency healthcare services (Flojstrup et al 2023). The objective of that study was the following: To investigate how the’ natural experiment’ of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. It was a stepped-wedge reconfiguration of the entire Danish emergency healthcare system. The main outcome was the adjusted odds ratio for in-hospital mortality and hazard ratio for 30-day mortality with some pre-specified subgroups. They found no statistical difference for in-hospital mortality but slightly increased 30-day mortality. The pre-specified subgroup analyses showed a decrease in in-hospital or 30-day mortality for myocardial infarction, stroke, aortic aneurysm, and major trauma but not for pneumonia, bowel perforation or hip fractures. This was not the only study to come out of the Danish reconfiguration initiative. The dataset also reported increasing admissions, mixed results on length of stay, increasing readmission rates, increasing COPD deaths if transported by ambulance, and expected productivity benefits were not realized. The SGEM advocated for having the evidence to inform/guide our decisions. Here is what the evidence say about the centralization of emergency healthcare services from the Danish study: some possible benefits for small groups of patients (myocardial infarction, stroke, aortic aneurysm, major trauma), there was no overall improvement in the in-hospital mortality trend and a slight worsening of the 30-day mortality trend. Five Assumptions Made about Emergency Healthcare Centralization Listen to the SGEM podcast to hear Louella and John discuss the five assumptions. Listed are the assumptions and some of the points we touched upon. Assumption#1: There is a problem with the quality of EM care that needs to be fixed Boarded patients length of stay (LOS) in the ED increases mortality Canary in the coal mine (fix the mine not the canary) COVID19 and staffing It’s about a system problem not a small hospital problem Assumption#2: Smaller hospitals provide worse care than their larger counterparts Myocardial infarction, stroke, and major trauma account for 1% of ED attendance Other skilled time-sensitive interventions (abdominal, vascular, obstetrical, and intracranial surgeries) still only amount to a total of 5% of ED attendance Little or no evidence that care in small hospitals is worse for 95% of cases Assumption#3: Reconfiguration produces better outcomes While studies of centralisation of care for individual services show better outcomes for specific patient groups, the population-level evidence for whole-scale reconfiguration through changes to ED services tells a different story.