Article Figures & Data
Figures
- Figure 1
Recruitment process.
- Figure 2
Effects on physicians and development of themes.
Tables
Practice Settinga Characteristic Total (N=42) Underserved (n=21) Nonunderserved (n=21) Age, y 48±12 50±14 46±10 Female 45 (19) 43 (9) 48 (10) Marital status Married 60 (25) 57 (12) 62 (13) Single 19 (8) 29 (6) 10 (2) Divorced 10 (4) 10 (2) 10 (2) Other 11 (5) 4 (1) 18 (4) Income distribution <$100K 7 (3) 5 (1) 10 (2) $100K-$149K 26 (11) 24 (5) 28 (6) $150K-$199K 33 (14) 38 (8) 28 (6) $200K-$249K 21 (9) 19 (4) 24 (5) ≥$250K 12 (5) 14 (3) 10 (2) Medical education California 69 (29) 71 (15) 67 (14) Public 76 (32) 81 (17) 71 (15) Residency training in California 69 (29) 67 (14) 71 (15) Specialty distribution Family medicine 48 (20) 52 (11) 43 (9) Internal medicine 31 (13) 19 (4) 43 (9) Pediatrics 17 (7) 24 (5) 9 (2) Other primary care 5 (2) 5 (1) 5 (1) Practice setting Staff model HMO/Kaiser 26 (11) 10 (2) 43 (9) Community/public clinic 31 (13) 62 (13) 0 (0) University 21 (9) 10 (2) 33 (7) Private practice 21 (9) 19 (4) 24 (5) No. reporting they were affected by closure 28 19 9 Distance from closed hospital, miles 14.2 9.1 19.4 No. of themes per physician 1.97 3.0 1.67 -
HMO=health maintenance organization.
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Note: Values are expressed as number, mean (±SD), or percent (no.).
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↵a No statistically significant differences were seen between physicians in underserved and nonunder-served settings, except for practice setting, using χ2 tests (P <.05).
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- Table 2
Sample Quotations by Primary Care Physicians in Underserved and Nonunderserved Settings
Theme and Subtheme Sample Quotations Physicians in Underserved Settings Physicians in Nonunderserved Settings Changes to local and regional health care system capacity Inpatient care over capacity “Now everybody has to be transported who needs to be admitted, because we don’t have any inpatient facilities per se.” — Emergency department overcrowding “…we don’t have emergency room, we only have the urgent care that is very limited.” “You’re seeing more uninsured patients that are affected…. They tend to be sicker because they’re not getting any care anywhere. You know, an emergency room is an emergency room.” Decreased access to specialists “And even though the hospital here is now called a multiambulatory care center, especially in pediatrics, some of the specialty services we were providing we’re not providing anymore, because they moved them out of the hospital.” — Decreased access to elective surgery “I mean, even before closures, sometimes elective surgery, you’d have to wait a year before you had your surgery, so I don’t know that it’s worse than that now. I mean, that’s pretty bad.” “I said I didn’t have access of some specialty and somebody made the comment to me, well, you can just refer them over to UCLA. I though, what a naïve comment. Many of these people don’t have cars. They walked to the facility because that was their community backstop.” Difficulty for patients in navigating system of care Greater delays in care “That’s because they’re coming to [clinic] into emergency care. They’re coming to us bleeding and they’re coming to us where they should actually be going 911 and going to actual emergency rooms but they prefer to come to us lots of times.“ “…waiting times, so people are getting put off longer and longer times before they actually get authorized for surgical care. They just wait longer and then they get sicker.” Poorer access and lower quality of care “The fact that [the hospital closed] is also going to affect in terms of whether these people get their care. I mean where are people going to go? So, it’s going to be these ‘safety-nets’ that actually take them. The problem is the safety-nets are bursting….” “What we have seen has been a sharp increase in our volume because with County services—not just hospitals, but County services in general being cut back—a lot of [patients] have a lot fewer resources…. And there’s fewer places for them to go.” Workforce and training changes Loss of training sites and faculty “There’s no teaching. Recently they cut off even teaching to medical students.” “The residents are maybe a little bit busier because they’re taking a few more patients… the patients always present learning opportunities for the residents, so I don’t think that it’s a negative thing.” Workforce relocated “Then, when the hospital closed last summer, there was a huge exodus. Charles Drew University’s faculty, the practicing faculty completely disappeared…. I don’t think anybody appreciated… how valuable that medical staff was.” — - Table 3
Frequency of Themes Among Physicians Overall and by Practice Setting and Distance From Closed Hospital
Setting Distance Theme and Subtheme Total (N=42) Underserved (n=21) Nonunderserved (n=21) ≤12 Miles (n=17) >12 Miles (n=25) Changes to local and regional health care system capacity 24 16 8 14 10 Within the local area 16 12 4 11 5 Inpatient care over capacity 5 4 1 3 2 Emergency department overcrowding 4 4 0 4 0 Decreased access to specialists 10 7 3 7 3 Decreased access to elective surgery 5 5 0 4 1 Outside the local area 15 8 7 9 6 Inpatient care over capacity 7 4 3 3 4 Emergency department overcrowding 10 5 5 7 3 Decreased access to specialists 2 2 0 1 1 Greater difficulty with primary care linkages 4 4 0 2 2 Difficulty for patients in navigating system of care 11 9 2 6 5 Greater delays in care 6 5 1 4 2 Poorer access and lower quality of care 7 6 1 3 4 Workforce and training changes 15 14 1 8 7 Loss of training sites and faculty 10 9 1 6 4 Workforce relocated 8 7 1 4 4 No impact 14 2 12 4 10 -
Notes: Values are numbers of physicians. Numbers were tabulated from the total number of physicians who stated a quotation within the theme or subtheme.
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The Article in Brief
Effect of Closure of a Local Safety-Net Hospital on Primary Care Physicians' Perceptions of Their Role in Patient Care
Kara Odom Walker , and colleagues
Background In recent decades, large urban public hospitals, also known as safety-net hospitals, have closed in several major US cities. Previous research has shown that, following these closures, minority, elderly, and uninsured populations are at risk for poorer access and health outcomes. This study assesses the effects of a safety-net hospital closure on local primary care doctors.
What This Study Found The hospital closure had some effect on 67% of primary care doctors and their practices, including (1) reduced local access to specialist consultations, direct hospital admissions, and timely emergency room evaluation; (2) more patient delays in care and worse health outcomes resulting from poor patient understanding of the health care system changes; and (3) loss of colleagues and opportunities to teach residents and medical students. The impact of the closure was felt by doctors more than 20 miles away from the hospital.
Implications
- It is important to anticipate and address the challenges raised in this study, particularly as safety-net hospitals and primary care practices work to create effective medical homes to improve quality of care for underserved and uninsured populations
- The authors suggest that primary care physicians be informed and consulted when a major disruption to the health care delivery system is planned.
The Article in Brief
Effect of Closure of a Local Safety-Net Hospital on Primary Care Physicians' Perceptions of Their Role in Patient Care
Kara Odom Walker, and colleagues
Background In recent decades, large urban public hospitals, also known as safety-net hospitals, have closed in several major US cities. Previous research has shown that, following these closures, minority, elderly, and uninsured populations are at risk for poorer access and health outcomes. This study assesses the effects of a safety-net hospital closure on local primary care doctors.
What This Study Found The hospital closure had some effect on 67% of primary care doctors and their practices, including (1) reduced local access to specialist consultations, direct hospital admissions, and timely emergency room evaluation; (2) more patient delays in care and worse health outcomes resulting from poor patient understanding of the health care system changes; and (3) loss of colleagues and opportunities to teach residents and medical students. The impact of the closure was felt by doctors more than 20 miles away from the hospital.
Implications
- It is important to anticipate and address the challenges raised in this study, particularly as safety-net hospitals and primary care practices work to create effective medical homes to improve quality of care for underserved and uninsured populations.
- The authors suggest that primary care physicians be informed and consulted when a major disruption to the health care delivery system is planned.
Supplemental Appendix
Supplemental Appendix 1. Questions From the Interview Guide Developed With the Community Advisory Boar
Files in this Data Supplement:
- Data supplement: Appendix - PDF file, 1 page, 82KB
