Date of Award

Summer 2019

Document Type

Open Access Dissertation


Health Services and Policy Management

First Advisor

Janice C. Probst



Over 100 rural hospitals have closed in the U.S. since 2010. Continuous pressures on the rural health care delivery system suggest that the trajectory of closures will continue in at least the short-term. While the causes of rural hospital closures have been described in the literature, the effects on the health outcomes of populations that experience these closures are still poorly understood. The purpose of this study was to determine associations between rural hospital closures and in-hospital and 30-day post hospital discharge mortality rates for affected residents experiencing time-sensitive emergencies in two U.S. states.


Rural hospital closures were identified using a national dataset provided by The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Counties where closures occurred were matched to comparison counties, both with and without hospitals. Secondary data for all counties were obtained from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project and a statewide all-payer claims database to include patient encounters from hospital inpatient and Emergency Department records for a five-year period. These records were selected for those that included at least one of four Emergency Care Sensitive Conditions (ECSCs): acute myocardial infarction, stroke, sepsis, or trauma. Variations in in-hospital and 30-day post hospital discharge mortality from pre-closure to post-closure time periods were assessed using a difference-in-difference-in-difference study design.


In-hospital mortality associated with ECSCs was 8.2% in the pre-closure time period and 4.1% post-closure. For residents living in counties where closures occurred, in-hospital mortality declined more rapidly in the post-closure time period compared to residents living in other counties. This overall decline occurred despite a marked increase in in-hospital mortality in the first quarter after the closure compared to the two previous quarters. This initial surge in in-hospital mortality suggests delays in access to treatment for ECSCs immediately post-closure. Thirty-day post hospital discharge mortality associated with ECSCs (one state only) was 7.8% in the pre-closure time period and 8.0% post-closure. For residents of the closure county only, the 30-day post hospital discharge mortality rate slowed significantly in the time period following the closure. This suggests increased access to higher quality care in the aftermath of the closure but may also indicate that some residents chose not to seek care at all.


In-hospital and 30-day post hospital discharge mortality are both associated with rural hospital closures. Together, these associations are inconclusive in that they suggest either potential delays in care or increased access to higher quality care post rural hospital closure. Further studies are needed to better describe the relationship between rural hospital closures and mortality.


© 2019, Melinda A. Merrell