Research Brief

Rural hospital closures strain community ambulance services

Ambulance driving on road
Credit: gmnicholas

Rural hospital closures force patients in affected communities to travel longer distances for specialized or emergency care. A new study from the University of Minnesota School of Public Health shows that such closures place similar strain on emergency medical service (EMS) providers trying to get patients to the hospital or another facility as quickly as possible.

The study was led by Associate Professor Sayeh Nikpay and recently published in the journal Academic Emergency Medicine.

EMS services in rural areas are provided by municipal agencies — such as police, firefighting and community volunteer organizations — or private companies that bid to offer transportation for a contracted period of time. 

To learn more, Nikpay and her research team searched publically available data for the locations of recent rural hospital closures across the U.S occurring in 2012-2018 and the names of EMS providers in those counties. The researchers then scoured Medicare payment data for EMS trip charges to patients in those areas during that time period. The charges were separated based on whether they were for emergency, interfacility or medical appointment transportation. The researchers compiled the information to calculate the number of trips made and their distance, and the type of trip.

The study found:

  • The average length of ambulance trips for municipal EMS agencies went up 22% in locations of recent rural hospital closures.
  • The average length of ambulance trips for private EMS agencies increased 10% in those areas.
  • Interfacility transfers and non-emergency EMS trips fell by 31% for all agencies.
  • The total number of trips did not change, likely because many agencies are already operating at full capacity and must prioritize emergency calls over transfers and non-emergency transportation after hospitals close.

“We found that hospital closures are a much bigger burden for public than private EMS agencies,” said Nikpay. “When hospitals close, municipal EMS agencies are forced to adjust, often hampered by tight budgets, limited personnel and other constraints. As for private companies, they have the option to walk away when the current contract expires if they feel it’s no longer worth it.”

The researchers are concerned that the pressure on rural public EMS agencies is increasing wear and tear on equipment; the amount of “dead time” spent returning to ambulance bases; and employee overtime and burnout. The situation is also decreasing the amount of time EMS providers have to restock and maintain vehicles and forcing providers to forgo providing routine medical appointment runs and instead rely on the unpredictable calls for emergency transportation as their main revenue stream.

The net result for the health of people ranges from making it more difficult to obtain rides for clinic visits that could keep them out of hospitals to potentially causing delays or denials to rush them to the emergency department when they need it most.  

Nikpay says the findings show that policymakers need to be prepared to increase funding to pay for added equipment, vehicles, facilities and personnel to bolster rural EMS agencies in areas where hospitals close.

Nikpay is continuing her research into rural ambulance services by partnering with the University’s Rural Health Research Center and a newly formed emergency medicine health services research group with emergency medicine physicians at Hennepin County Medical Center, the University of Minnesota Department, and Vanderbilt University to study more comprehensively how hospital closures are affecting EMS providers in Minnesota and Tennessee.


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