Impact of rural hospital closures in Saskatchewan, Canada

Social Science & Medicine 52 (2001) 1793–1804

Impact of rural hospital closures in Saskatchewan, Canada

Liyan Liu, Joanne Hader*, Bonnie Brossart, Robin White, Steven Lewis

Health Services Utilization and Research Commission (HSURC), Box 46, 103 Hospital Drive, Saskatoon, Saskatchewan,

Canada S7N 0W81

Abstract

Canada’s health care system has undergone major changes since 1990. In Saskatchewan, 52 small rural hospitalsfunded for less than eight beds stopped receiving funding for acute care services in 1993. Most were subsequently

converted to primary health care centers. Since then, concerns have been raised about the impact of the changes onrural residents’ access to care, their health status, and the viability of rural communities. To assess the impact ofhospital closures on the affected communities, we conducted a multi-faceted, province-wide study. We looked athospital use patterns, health status, rural residents’ perceptions of the impact of these hospital closures, and how

communities responded to the changes. We found the hospital closures did not adversely affect rural residents’ healthstatus or their access to inpatient hospital services. Despite widespread fears that health status would decline, residentsin these communities reported that hospital closures did not adversely affect their own health. Although some

communities continue to struggle with changes to health care delivery, others appear to have adapted as a result ofstrong community leadership, the development of widely accepted alternative services, and local support for creatinginnovative solutions. Good rural health care does not depend on the presence of a very small hospital that cannot,

in today’s environment, provide genuinely acute care. It requires creative approaches to the provision of primarycare, good emergency services, and good communication with the public on the intent and outcomes ofchange. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Rural hospital closures; Community impacts; Health care reform; Health policy; Saskatchewan; Canada

Introduction

Saskatchewan has been a leader in health care inCanada for almost 50 years. The province pioneered

universal hospital care insurance in 1947 and compre-hensive medical coverage in 1962. Saskatchewan began amajor reform process designed to renew the health

system in 1992. The conceptual cornerstone of the newapproach was the wellness model and a shift frominstitutional to community care. The wellness model

emphasizes preventive care and innovative servicedelivery within a system of 33 health districts. The need

for this shift in emphasis and structure is best illustratedby the fact that in 1992, Saskatchewan had 134 hospitalsfor a population of one million people } more than inQuebec, for example, with a population seven times

larger. As a consequence, utilization rates were high andthe populace identified strongly with a brick-and-mortarapproach to health care.

Fiscal circumstances in the 1990s also increasedpressures for change. In 1982 the province had noaccumulated operating debt. By 1991, after two terms of

Progressive Conservative government, the cumulateddeficit had reached nearly $9 billion (Canadian). Theprovince’s credit rating declined steadily through the

1980s. When the New Democratic Party resumed powerin 1991 it faced a daunting situation: there were threatsof further downgrading of the credit rating, raising thepossibility that the province could no longer borrow

money to cover any operating deficit. Since health care

*Corresponding author. Tel.: +1-800-655-1599; fax: +1-

306-655-1462.

E-mail addresses: [email protected] (L. Liu), [email protected]

(J. Hader).1http://sdh.sk.ca/hsurc

0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 2 9 8 - 7

consumed a third of the provincial budget, it was anobvious target for restraint.

To accelerate the shift from institutional to commu-nity care and as a cost-containment measure, theSaskatchewan government announced the conversion

of 52 small rural hospitals to health centers in 1992. Allof these affected hospitals but two had less than 25 beds;none received funding in 1992 for more than eight beds.These hospitals were located in towns with about 500

people. They did not perform surgery. Of the 52hospitals, 23 were integrated facilities with both acuteand long-term care beds. These 23 continued to receive

funding to operate as long-term care facilities. Theremaining 29 hospitals were given one-time only fundingto convert to wellness centers. Many of these wellness

centers operate five days a week with full-time staffing bynurses and part-time physician visits. In addition to theconversion to wellness centres, the withdrawal of acute

care funding was counterbalanced by the expansion ofprimary care, emergency, physiotherapy, home care, andlong-term care services. Since the funding cuts, concernshave been raised about the impact of these changes on

rural residents’ access to care and health status. Inaddition, the health care providers and the publicworried about the potential loss of local jobs, a further

decline in the economy, and out-migration of some ruralresidents (James, 1999).

In Canada, several other researchers have examined

the effect of bed closure (Roos & Shapiro, 1995) andhospital restructuring (Anderson, 1997). None hasassessed the impact of hospital closure. In the UnitedStates, a few studies have assessed the impacts of

hospital closures. Most found little effect on access tohospital care (McKay & Coventry, 1995; Fleming,Williamson, Hicks, & Rife, 1995; U.S. Congress,

1991a; Mullner & McNeil, 1986; Samuels, Cunning-ham, & Choi, 1989; Burda, 1992; U.S. Department ofHealth and Human Services, 1989; Hendricks & Alberts,

1989) and the health of rural residents (McKay &Coventry, 1995; Fleming et al., 1995; U.S. Congress,1991a). Others reported that access (Bindman, Keane,

& Lurie, 1990; Rosenbach & Dayhoff, 1995; Hart,Pirani, & Rosenblatt, 1991, American Hospital Associa-tion, 1989; U.S. Congress, 1991b) and health status(Bindman et al., 1990; Rosenbach and Dayhoff, 1995;

Hart et al., 1991) had deteriorated in communities afterhospital closure. In particular, the elderly, the poor, andthose needing emergency care were disproportionately

affected.Most of these were American studies of rural

hospitals two to four times the size of the affected

Saskatchewan rural hospitals. The conclusions thereforewere of limited applicability to Saskatchewan. We did,however, build our study design on the previous work.

Most of the previous studies used hospitalization rates,number of people hospitalized, and episode of care as

indicators for access; and used mortality as an indicatorfor overall health status. We also chose mortality

because it is a robust indicator for health status.Mortality has been used by many countries to assesshealth status across populations, for example, Health

For All in the Twenty-First Century (The World HealthOrganization, 2000) and Healthy People 2010 (U.S.Department of Health and Human Services, 2000). Astudy from Canada (Cohen & Macwilliam 1995)

concluded ‘‘mortality indicators alone appear to besensitive to differences in health status acrosspopulations’’. Rosenbach and Dayhoff (1995) used a

pre, post-design as well as trend analysis to determinewhether rural hospital closures have had a detrimentalimpact on access to inpatient and outpatient care.

James (1999) has assessed the impact of rural hospitalclosures by reviewing the history of the Saskatchewanhospital conversion process and the meaning of local

hospitals for rural communities. Our study assessed theimpact of closures by focusing on health status, hospitalutilization, and residents’ perceptions. This reportsummarizes our findings. We hope this study will

stimulate public discussion and inform health careplanning at the community, provincial, national, andinternational levels.

Methods

In 1997, the Health Services Utilization and ResearchCommission (HSURC) formed a working group of

representatives from a number of rural communities. Itcomprised physicians, a nurse administrator, citizens whohave served on rural health boards, and a sociologist andagricultural economist both knowledgeable in rural

issues. The working group provided direction to HSURCstaff throughout the research project.

To fully examine the impact of the closure of rural

Saskatchewan hospitals, we sought answers to thefollowing research questions:

* Were there any changes in inpatient hospital use bypeople in the closure communities?

* Were there any changes in the health status of

residents in the closure communities?* What were community members’ perceptions of the

impact of the changes on access to health services,quality of health services, personal health status, and

community viability?* How did communities respond collectively to the

1993 hospital closures?

To address these questions we did three sub-studies:(1) hospital use and health status } an administrative

data analysis; (2) public perceptions } a telephonesurvey; and (3) communities’ response } focus groups.

L. Liu et al. / Social Science & Medicine 52 (2001) 1793–18041794

Hospital use and health status } administrative dataanalysis

We obtained from the Saskatchewan Ministry ofHealth the hospital separation and mortality data

for fiscal years 1990–1996. The hospital separationdata file contains patient information on encrypted ID,age, sex, admission date, discharge date, diagnoses,procedures performed during the hospital stay, and

residence code for geography. It contains all theovernight stays in Saskatchewan. Day-surgeries are notincluded. The mortality data file contains age, sex,

leading cause of death, other cause of death, andresidence code.

To assess if the 1993 hospital closures affected

hospital care, we calculated three measurements: (1)the number of people hospitalized per 1000 people; (2)hospitalization per 1000 people; and (3) episode of care

per 1000 people. Health services researchers oftenemphasize the limitations of working with hospitaldischarge data, arguing the importance of trackingindividuals, not hospitalizations. In Saskatchewan, we

are able to calculate the number of people hospitalizedusing the encrypted identifier. Furthermore, it is possiblethat many transfers may occur from rural to urban

hospitals, leading to double counting of hospitalizations.In Saskatchewan we are able to calculate episode of careby combining sequential hospitalizations at one or more

hospitals as a single episode of care.To assess if the health of rural residents was adversely

affected by the closures, we calculated overall mortality,premature mortality, and cause-specific mortality. We

looked at acute myocardial infarction, motor vehicleinjuries, and stroke. We selected these particularconditions because patients may die if adequate inter-

vention is not available within distance-sensitive timeperiods.

We used the Heath Insurance Registration File

(HIRF) from the Saskatchewan Ministry of Health tocreate denominators and the 1993 data as standardpopulation for age-, sex-standardized rates. Because

Saskatchewan has a publicly funded, universal healthcare system without user premiums, the HIRF coversover 99% of Saskatchewan residents.

Our unit of analysis is the group of closure commu-

nities, not hospitals. We compared the closure group’shospital use and mortality data to three comparisongroups:

* rural communities that never had a hospital;* rural communities that still have a hospital; and,* the rest of Saskatchewan.

We chose these comparison groups to control for

external factors that may account for changes in hospitalaccess independent of the hospital closures. Without an

independent comparison group, it may appear straight-forward to attribute a reduction in hospital separation

rates to hospital closure, when in fact hospital separa-tions have been declining both provincially and nation-ally since 1990.

We chose communities that never had a hospital tohelp explain what could happen to communities aftertheir hospital no longer provides acute care services. Toensure this group was as similar as possible to the closure

group, we matched the never group with the closuregroup on population size, population density, elderlydependency ratio (i.e., the ratio of people aged 65 years

and older to the population aged 15–64), and Stablerand Olfert’s (1996) classification of community econom-ic viability. This group consists of 46 communities with a

total population of over 52,000.To explain what might have happened in the closure

group had they retained their hospitals, we created a still

group of communities with populations of less than 1500that continue to have a hospital with fewer than 20funded beds. This group consists of 28 communities witha total population of over 61,000.

Finally, we created a rest of Saskatchewan group toprovide an overall summary of hospital use and healthstatus patterns over the study period throughout the

province. This group mostly represents the largeurbanized cities of Saskatoon and Regina. It alsoincludes far northern areas. We did use ‘‘Saskatchewan

overall’’ for a comparison group and the results werealmost identical to that using The rest of Saskatchewancommunities. To keep the groups mutually exclusive, wepresent the results using the rest of Saskatchewan as the

comparison group.For the closure group, we confined our analysis to the

communities in which hospitals were closed in 1993. We

excluded two communities whose hospital closed in 1994and another three communities that are within closeproximity of a small hospital that remains open. Thus

there were 47 communities in the closure group with atotal population of over 56,000 per year.

We employed a design of pre-, post-closure compar-

ison and trend analysis. We used profile analysis(Morrison, 1976) to detect meaningful difference inhospitalization trends over time between the closuregroup and the comparison groups. Profile analysis

was performed in SAS using the profile option in thePROC GLM procedure (SAS Institute, Inc., 1989).Since the number of hospitalizations was so large, the

confidence intervals for hospitalization rates wereextremely narrow. Thus we did not present confidenceintervals for the hospitalization rates (data available

upon request). For mortality, we performed a z-test(Kahn & Sempos 1989) to determine if the differencebetween pre- and post-closure rates is statistically

significant among study groups. We also calculatedconfidence intervals for each mortality rate.

L. Liu et al. / Social Science & Medicine 52 (2001) 1793–1804 1795

Public perceptions } telephone survey

The purpose of the survey was to find out howresidents thought the closures had affected their accessto health services, their health status, and their commu-

nity’s viability. We asked questions pertaining to threetime periods: the time before the closures (prior to 1993);the time of closures (1993–1994); and the time of thesurvey (fall 1998). We used a stratified random sampling

strategy to ensure the inclusion of a community fromeach health district that experienced a hospital closure.In health districts where more than one hospital was

affected, we randomly selected one community. Thetarget population for telephone interviewing was allpersons aged 26 and older at the time of the survey (i.e.,

people who were adults for the entire study period,1990–1996), who lived within a 30 km drive of the closedhospital, who were aware of the hospital closure, and

who could be contacted by telephone. We randomlysampled about 250 people from each community.

We mailed a pre-notification announcement of thesurvey to all residents of the selected communities and

ran newspaper advertisements in the local weeklynewspapers. A 20-station CATI (computer-assistedtelephone interview) system was used in the data

collection.We interviewed 5270 rural Saskatchewan residents in

25 of the 52 closure communities. The young (aged 26–

44), the middle aged (45–64), and the elderly (65+) wereevenly represented in the study, 33, 38, and 29%respectively. In order to recruit an equal number ofmale and female respondents, interviewers asked to

speak to an eligible person with the next birthday.Despite these efforts, two-thirds of respondents werefemales. Using the Health Insurance Registration File

(HIRF), we age- and sex-weighted our results to the1997 Saskatchewan population to adjust for theimbalance in response rates by gender.

Communities’ responses } focus groups

We conducted 19 focus groups in 10 communities toexamine the range of communities’ experiences with andresponses to the hospital closure. We asked local

residents about how their community responded to thechanges in health service delivery and the factors theythought helped or hindered their community’s ap-proach. We also asked them to identify their key

concerns about the changes to health care deliveryresulting from these hospital closures.

Our goal in selecting these communities was to collect

information on a range of experiences with, andresponses to the closures. Specifically, we pickedcommunities that varied in such attributes as geographic

location, changes in its population and services over a30-year period, the proportion of residents 65 and older,

and type of facility in the community prior to thehospital closures (i.e., standalone hospital, integrated

facility, or hospital with separate special care home). Wealso wanted to ensure that we selected communities witha variety of responses, both positive and negative, to the

closures. Some communities approached us to requestthat a focus group be held. Four of the 10 sites werechosen on this basis.

To identify focus group participants, we first con-

tacted three people in each community (the health centeradministrator, town or rural municipality administrator,and a leading business person or citizen active in

community work). We asked them to nominate indivi-duals knowledgeable about that community’s responseto the 1993 acute care funding cuts. We aggregated these

lists and asked two of the key contacts to re-nominatepeople. From the lists we invited individuals who werenominated at least twice, along with others, to make

sure the groups had variation in background andconsistency. Focus group sizes ranged from 6 to 12people.

Each focus group followed a standard interview

protocol. The questions were designed to generateinformation on the character of the community, how itlearned of the hospital closure, the steps the community

took to cope, the feelings it had both initially andcurrently, why the community thought things hadhappened the way they did, factors that made coping

more difficult, and factors that helped the community tocope. We audio-taped and transcribed all focus groupdiscussions. Two researchers independently developedand applied codes to the data, regularly comparing these

analyses as a reliability measure. We then organized andcompressed the data into a framework that wouldenable us to both verify the data and generate

conclusions.

Results

Hospital use and health status } administrative data

analysis

We used three rates to measure hospital use: number

of people hospitalized, hospitalization rates, and episodeof care. They yielded similar results } hospital use hasdeclined throughout the province (Table 1 and Fig. 1).The closure communities had the sharpest decline in

rates; communities that still have small rural hospitalscontinue to have the highest rates of hospital use. Thedeclining trend in the closure group was significantly

different from the still group, but not significantlydifferent from the never or the rest of Saskatchewangroups.

When we looked at age-specific hospitalization rates,the reduction is most evident in the older age groups for


Table 1

Hospital utilization and health status patterns before and after the hospital closuresa

Communities affected

by 1993 hospital closures

Communities still

with small hospitals

Communities that never

had a hospital

Rest of Saskatchewan

1990–92 1993–96 1990–92 1993–96 1990–92 1993–96 1990–92 1993–96

Driving distance to nearest hospital

(km)

Average (standard deviation) 51 (18.7) 41 (15.9)

Hospitalization rates

Number of people hospitalized

per 1000 people

110.4 86.8 113.4 102.4 99.8 88.8 105.0 95.5

Hospitalization per 1000 people 229.9 144.8 247.0 194.9 190.9 153.1 206.2 167.1

Base hospitals (%) 28 36 26 26 35 38 45 48

Regional hospitals (%) 13 21 9 11 15 15 17 19

Large community hospitals (%) 9 15 5 6 13 15 9 9

Community hospitals (%) 50 27 60 57 37 32 29 24

Episode of care per 1000 peopleb 205.2 133.4 222.5 175.3 175.1 140.7 192.1 155.9

Length of in-hospital stay (LOS)

Average LOS per hospitalization 8.3 7.1 7.8 7.0 7.7 6.9 7.5 6.6

Patient-days per 1000 people 1732.0 919.1 1735.3 1197.9 1397.0 985.7 1567.7 1098.9

Mortality per 100,000 people

Mortality, all causes 803.1 754.4 853.3 833.1 684.9 651.1 788.3 774.8

(767.2–839.0) (724.8–784.0) (818.9–887.7) (803.9–862.3) (648.4–721.4) (620.5–681.7) (776.7–799.9) (765.1–784.5)

Acute myocardial infarction 117.2 87.1 113.7 90.7 116.9 76.1 100.6 83.8

(103.7–130.7) (77.1–97.1) (101.3–126.1) (81.1–100.3) (102.0–131.8) (65.8–86.4) (96.4–104.8) (80.6–87.0)

Motor vehicle injuries 22.9 16.6 18.9 21.4 23.6 17.7 14.0 11.4

(16.1–29.7) (11.5–21.7) (12.7–25.1) (14.9–27.9) (16.5–30.7) (12.1–23.3) (12.5–15.5) (10.3–12.5)

Stroke 59.4 53.1 61.0 59.3 53.3 47.2 56.7 57.1

(49.8–69.0) (45.4–60.8) (52.0–70.0) (51.8–66.8) (43.1–63.5) (39.0–55.4) (53.6–59.8) (54.5–59.7)

Premature mortality (aged 0–74) 329.3 297.3 325.3 339.0 271.3 266.6 317.6 304.7

(305.3–353.3) (277.2–317.4) (302.3–348.3) (315.3–363.0) (248.4–294.2) (246.4–286.8) (310.4–324.8) (298.7–310.7)

Population size 59,955 56,873 55,747 53,807 56,334 53,433 846,905 856,157

aAll rates are age, sex standardized to 1993 Saskatchewan populationbAn episode of hospital care represents continuous use of hospital care that may include one or more transfers between facilities. This measure adjusts for bias introduced by

double counting separations for patients who are transferred from one hospital to another.

L.Liuetal./SocialScien

ce&Medicine52(2001)1793–1804

1797

the closure group compared to younger age and other

study groups (Table 2) Nevertheless, Saskatchewan’srates of hospital use continue to be much higher thannational figures (Fig. 1). This decline in hospital use is

likely due to many factors including the trend towardmore frequent use of ambulatory care and day surgery,the shift from hospital to community-based services,

increased emphasis on health promotion and diseaseprevention, service consolidation, improved medical tech-nologies and treatment as well as new pharmaceuticals.

We also wanted to know more about transfer patterns

before and after closures. Using the episode of care andhospitalization rates (Table 1), we calculated the transferrates } 24/1000 hospitalizations before the closures

(229.9–205.2) and 11/1000 after the closures (144.8–133.4).Table 1 also shows that patients now are spending

about one day less in hospital. As hospital use has been

declining, length of hospital stay also has been decliningfor a number of reasons. Many services traditionallyrequiring hospitalization are shifting to ambulatory care

programs such as gallstone removal. In addition,patients, such as those undergoing angioplasty proce-dures, are being operated with less invasive surgery anddischarged sooner.

Communities with small hospitals have higher averagelengths of stay both before and after the closure,compared to the rest of Saskatchewan group (Table 1).

This likely reflects higher rates of non-acute use. Ourearlier study (Health Services Utilization and ResearchCommission, 1994) found that many days in hospital

were not acute and in small hospitals in particular bedswere often used for long-term care or waiting for long-term care beds.

When we looked at distance to hospital as an

additional measure of access, we found residents of the

closure communities must now drive an average of51 km to the closest hospital. People living in commu-

nities that never had a hospital travel on average 40 kmto the nearest hospital, 10min less than those affected byhospital closure (Table 1).

Health status, as measured by mortality rates,improved throughout the province during the studyperiod (Table 1). Communities that experienced thehospital closures had the largest overall reduction in

mortality rates; communities that still have smallhospitals, the smallest. As a matter of fact, thecommunities that still have small hospitals experienced

a slight increase in premature mortality and mortalityfor injuries, although this increase is statistically notsignificant. Communities that never had a hospital had

the lowest mortality rates throughout the study period.

Public perceptions } telephone survey

We surveyed 5270 rural residents whose local hospitalwas closed. Roughly one-third of the respondents wereaged 26–44, one third aged 45–64, the rest over 65 years

old.We found a sharp contrast between what people

anticipated and what they believe now. When we asked

the question ‘‘when you heard about the funding cuts in1993, did you think that your overall use of healthservices might greatly decrease, somewhat decrease, stay

about the same, somewhat increase, or greatly increase’’,57% of survey respondents answered ‘‘greatly decrease’’or ‘‘somewhat decrease’’. When we asked about current

perception, 74% reported their use was the same or hadincreased. This difference is statistically significant at0.01 level.

Upon hearing of the hospital closure, over 60% of

respondents anticipated their personal health and thehealth of other people in their household would beharmed. They were most concerned about reduced

access to emergency services, the need to travel fartherfor health care, and decreased availability of healthservices in general. Contrary to what they anticipated,

89% of respondents reported at the time of the surveythat the hospital closures had no effect on their personalhealth. (Fig. 2). In addition, 64% of people surveyed

said they are now in good health. This is comparablewith provincial (56%) and national figures (64%) onself-rated health based on the National PopulationHealth Survey (Statistics Canada, 1995).

Over half of the survey participants anticipated adecrease in population size and in the number of jobs intheir town as a result of the hospital closure. Five years

later, most respondents reported that the overall popula-tion size, number of jobs, and personal income eitherstayed the same or had somewhat decreased (Fig. 3).

Only 10% believed the hospital closure was responsiblefor any changes to town size, number of jobs, or

Fig. 1. Age-, sex-standardized hospitalization rates per 1000

population: 1999–1996.


personal income. Respondents identified agriculture,natural resources, and other local business as the factors

most responsible for the survival of their towns.We also asked the survey participants about their

satisfaction with health services. Most respondents(82%) recalled being satisfied with health services prior

to the 1993 hospital closures. However, over half (54%)are now dissatisfied with current health services. Whenasked why they are dissatisfied, most respondents said

that doctor and emergency services are now lessavailable.

Communities responses } focus groups

Communities responded in a variety of ways to news

of the hospital closure. Most pulled together andcooperatively worked toward one or several ends.

Many communities, at least initially, hoped to stopthe hospital closures and keep their building open.

‘‘People of the community got together to try toeither delay it or postpone it or cancel this decision.’’

In one community, leaders focused their energy onhelping residents cope with the changes by focusing on

the district formation process.

‘‘I think we just knew . . . it was cut and dried, so what

were we going to do about it? I think what we had todecide was how are we going to cope with this.’’

Other communities worked toward ensuring‘‘needed’’ health services were in place, retainingcontrol of the hospital trust money (most hospitals

had fundraising mechanisms and some had accu-mulated significant amounts), and resolving problemsrelated to local primary care services (e.g., keeping orrecruiting a local physician or employing advanced

clinical nurses).Table

2

Age-

sex-sp

ecifi

chosp

italiza

tion

per

1000

peo

ple

Com

munitiesaffec

ted

by

1993

hosp

italclosu

res

% diff

eren

ce

Com

munitiesstillwith

small

hosp

itals

% diff

eren

ce

Com

munitiesth

atnever

had

ahosp

ital

% diff

eren

ce

Res

tof

Sask

atchew

an

% diff

eren

ce

1990–92

1993–96

1990–92

1993–96

1990–92

1993–96

1990–92

1993–96

Rate

Rate

Rate

Rate

Rate

Rate

Rate

Rate

Male 0–24

136.7

89.9

34

145.9

114.0

22

111.3

88.2

21

148.6

119.5

20

25–44

86.2

57.0

34

97.0

78.0

20

76.5

62.8

18

76.8

64.6

16

45–64

214.4

137.2

36

207.7

161.6

22

173.4

139.6

19

174.2

144.6

17

65–74

494.1

328.2

34

512.2

410.8

20

421.2

349.4

17

392.4

344.3

12

75+

947.4

533.2

44

957.5

792.6

17

722.7

629.3

13

676.7

587.0

13

Fem

ale

0–24

161.4

109.4

32

185.9

145.9

22

143.8

114.9

20

188.1

156.4

17

25–44

219.0

152.4

30

232.3

183.6

21

180.9

147.5

18

194.2

160.4

17

45–64

217.2

138.3

36

240.0

183.5

24

181.3

138.0

24

177.8

140.7

21

65–74

400.4

232.7

42

453.8

348.9

23

330.4

265.2

20

308.1

258.7

16

75+

795.2

416.8

48

850.6

670.7

21

651.5

485.4

25

542.9

452.9

17

Fig. 2. Rural residents’ perceptions about the impact of

hospital closure cuts on health status.


Community strategiesCommunities employed a number of strategies to

achieve their goals.

‘‘. . .small-town rural, prairie people are resilient. Just

because one thing doesn’t work, well we’ll live withthat and try something else . . .’’

Most communities actively lobbied the SaskatchewanMinistry of Health and local politicians by writingletters, attending rallies, and holding town meetings.

Many made their case by researching local needs;negotiating with local health districts; working coopera-tively with towns, rural municipalities, and healthdistrict staff; forming advisory committees; and partici-

pating on district committees.

Community concerns

A number of concerns were raised about how theSaskatchewan Ministry of Health handled the hospitalclosures. Their primary concern was that before the

announcement of the hospital closures people living inrural communities had not been made aware of anyoverall long-range plan for local health services that

included alternative arrangements for primary andemergency care.

‘‘Well. I think there was a lot of fear that once we lostthe acute care beds then we would lose emergency

and then we would lose the lab and then we wouldlose. It was fear of the unknown I think.’’

In many communities the transition was more difficultbecause of the lag time between the announcement ofthe hospital closures and the establishment of healthdistricts to work with communities in arranging alter-

nate services.Many community leaders did not know how to take

the bad news to the communities. They were frustrated

because the Saskatchewan Ministry of Health was notable to provide any guidance.

‘‘They [the government] gave us some deadlines andsaid there was going to be a process to accomplish it.

They answered a few of those questions but theydidn’t give us any help on how to come home and tellthis to the whole community.’’

People in the communities were frustrated becausethey did not know what was going on and did not feelthey were consulted.

‘‘They never reached out to the communitiesthemselves and said, ‘How do you think it would

Fig. 3. Rural residents’ perceptions about the impact of hospital closure on community viability.


best be handled?’. . .I mean we all know if we’ve gotinefficiencies [we] can probably, given a bit of

time. . .address them. . . .the frustration comes fromloss of local control. Who knows your communitybetter than you?. . .They just felt that it didn’t matter

what they said or what they did, nothing was going todo any good anyway. So they became very apatheticand didn’t contribute a lot.’’

Many people told us that the community consultationprocesses did not appear to be legitimate (i.e., theyperceived outcomes were pre-arranged). More impor-

tantly, they believed it showed great disrespect to‘‘pioneers’’ who helped establish community hospitalservices.

‘‘They. . .built this community, plan to retire here.The last thing they want is to be in some geriatric

center in Regina not knowing anybody, and beingscared to die alone.’’

Finally, many felt the manner in which the hospitalclosures were handled unnecessarily increased fear,anger, and instability in most of the affected commu-nities and today health districts still have to deal with

this lingering bitterness and disillusionment.

Community satisfactionOnly a few communities were satisfied with the

outcomes of their collective response to the hospital

closure. Despite now having a variety of health servicesnot previously available locally, many communitiescontinue to be unhappy. Several factors were associated

with a community’s level of satisfaction with theoutcomes of their responses to the hospital closure.These factors are interrelated and include:

* Strong, committed leadership (in the communityand in other organizations) that is open to inno-vative solutions, uses flexible problem solving, and is

able to establish and maintain non-adversarialrelationships.

‘‘We have some individuals that are hard workingand very enthused to keep it a thriving commu-nity. . .one of the few that is thriving and growing and

that is due to I think some of the citizens that arereally working at it.’’

* Good communication and information sharing with-

in the community, among leaders, and with outsideagencies.

* Addressing local primary care and emergency health

services issues, by providing needed services andworking with residents to redefine health care needs.

‘‘I think we’ve learned to redefine the word emer-gency too. Like so many people. . .have learned that

[it] isn’t so acute anymore. . .’’‘‘Retraining the public. . .things have changed. . .It took the community quite a while to adapt to

that . . .’’

* A transparent planning process that draws on

existing community expertise, is open to innovativesolutions, and is tailored to local community needs.

* Supportive local health care providers willing to

work together to find innovative local solutions tomeet primary care and emergency care needs.

Discussion

Strengths and limitations

This study is unique in that it is the only comprehen-sive assessment of the impacts of rural hospital closure.The study is also strengthened by its pre-, post-

comparison, use of four study groups, and the assess-ment of trends over time. The impacts of hospitalclosures go beyond measures of access to care and health

status. We therefore complemented our administrativedata analysis with a telephone survey and focus groupdiscussions to hear rural resident’s perspectives.

We excluded the First Nation’s people (aboriginalpopulation assigned status by virtue of historical treaties)in the analysis due to the way residence was coded on the

administrative database. During the study period, theresidence of First Nations people was attributed to thereserve occupied by the band to which they belongedrather than where they actually lived. First Nation’s

people constitute about 9% of Saskatchewan population.This limitation could be expected to lead to an under-estimation of both hospitalization and mortality rates.

We did not study the migration patterns of individualrural resident. It has been argued that the mostvulnerable people may have moved to communities that

still have hospitals. We did investigate the overallpopulation pattern by community. Closure, still, andnever communities all experienced population lossduring the study period. This migration however was

in younger age groups. In fact, the population of those75+ increased 8% in the closure group, 6% in the stillgroup, and 7% in the never group.

Was health status adversely affected by the hospitalclosure?

Closure of 52 rural Saskatchewan hospitals has notadversely affected the health status of residents in these

communities. Overall, mortality rates have declinedthroughout the province, with the largest decreases in


closure communities. Community residents’ perceptionswere consistent with the mortality data. Despite wide-

spread fears that health status would deteriorate, respon-dents overwhelmingly reported that the hospital closuresdid not adversely affect their own or their family’s health.

In addition, two out of three people surveyed rated theircurrent health status as either good or very good.

What about the communities that never had a hospital?

While it seems implausible that keeping a smallhospital open could adversely affect a community’s

health status, the data from the communities that neverhad a hospital raise some interesting questions. Overallmortality rates and mortality rates from heart attack

and stroke were lowest in these communities. It iscertainly plausible that other influences may account forthese patterns. For example, healthier people may be

more willing to live in a community without a hospitalwhile those people at greater risk of health problemschoose to live in communities with a hospital. On theother hand, it seems unlikely that people who leave

small towns without hospitals would for health carereasons move to other small towns with no specialistsand very small hospitals incapable of providing medical

expertise and technology-intensive service.Our results suggest a positive association between

health status and hospital closures. However, we are

unable to prove a direct cause-and-effect relationship.We do know that residents of the closure communitiesnearly halved their use of hospitals (in terms of hospital

days per 1000 people) and their health status indicatorsimproved to a greater extent than in the province’s othersmall communities. One possible explanation is thatsmall hospitals unintentionally create dependencies and

patterns of care that result in worse outcomes. Previouswork (Health Services Utilization and Research Com-mission, 1994) demonstrated that rural hospitals in the

province larger than those closed were used predomi-nantly for non-acute care. It would appear worthexamining why the communities that never had a

hospital are so healthy with less use of hospitals.

What do community residents think?

The participants in our telephone survey and focusgroups were not aware of the health status datapresented above. We do not know whether their

perceptions would have been different had they seenthe comparisons of outcomes between their communitiesand those that kept their small hospitals. However,

despite acknowledging that the hospital closures did notharm their health status, study participants continued toresent the changes. Focus group respondents criticized

the process by which the 1993 changes were commu-nicated. It is difficult to imagine a process that would

have made the communities more accepting of thechanges and of the general spirit of the poorly under-

stood wellness model, given the impending loss of animportant symbolic institution. That the resentmentpersisted five years after the event suggests that

acceptance of change is invariably difficult. There arelimits to what even the best communications andconsultation process could achieve. More recent propo-sals for amalgamating Saskatchewan’s 1000 municipa-

lities into either 125 larger units (The Task Force onMunicipal Legislative Renewal, 2000) or our home carestudy (Health Services Utilization and Research Com-

mission, 2000) have similarly provoked negative reac-tions from rural areas.

Two communities in which we held focus groups seem

to have adapted more positively to the change. Factorscited by participants as most helpful were strongcommunity leadership, the development of widely

accepted alternative services, and local support includ-ing physicians for doing things differently. These are notunlike the factors that promote rural communityviability in general in a changing environment shaped

by external trends and technologies.It has long been assumed that rural residents wanted

to keep their local hospitals because they provided both

jobs and a symbol of community viability. The surveyresults contradict this assumption. Respondents identi-fied general economic conditions and influences } not

health services } as the most important factors affectingcommunity viability. Other studies of public perceptionsof rural hospital closure (Muus, Ludtke, & Gibbens,1995) or bed closures (Shapiro, Tate, Wright, & Ploh-

man, 2000) are consistent with our study findings. Theyfound that the public was dissatisfied with the hospitalrestructuring. The public was mostly concerned about

access to emergency services and doctors, yet perceivedthe hospital restructuring had little impact on healthstatus and community viability.

Conclusions

Closing very small rural hospitals did not appear toadversely affect rural residents’ health status or access to

inpatient hospital services. Whether the hospital closuresactually affected community’s viability, residents did notperceive it to be a major factor. In this sense the impactof the restructuring of Saskatchewan’s hospital system

was not as great as anticipated, especially when oneconsiders that these small hospitals, despite severelylimited capacity to deliver genuine acute care, were very

expensive due to diseconomies of scale. The changeshave been problematic, however, from the standpoint ofcommunity acceptance and adaptation to new modes of

delivery. It bears repeating that individual and focusgroup respondents did not have any of the data on


health status prior to and after the closures as a framefor their views. They perceived only the loss of an

institution, the continuing uncertainty in the availabilityof primary care, and an overall sense of diminishedcommunity viability.

In conclusion, good rural health care does not dependon the presence of a very small hospital that cannot, intoday’s environment, provide genuinely acute care. Itrequires creative approaches to the provision of primary

care, good emergency services, and good communicationwith the public on the intent and outcomes of change.

Acknowledgements

We wish to thank the working group members fortheir dedication and guidance throughout this project.The working group members are: Jerry Danielson

(chair), Marianne Hodgson, James Irvine, MurrayKnuttila, Bernice MacDougall, Russ McPherson, M.Rose Olfert, Michael Smith, and Sandy Weseen.

We gratefully acknowledge Greg Basky, Kelly Ches-

sie, Barb Nisbet, and Laurie Thompson from HSURCfor their critical reading and helpful suggestions. Alsosincere thanks to all the rural residents who participated

in our telephone survey and focus group discussion.We sincerely thank Dr. Haiyi Xie at Dartmouth

Medical School, Lebanon, New Hempshire, USA for his

statistical advice.We contracted Moore, Chamberlin and Associates

(MCA) to organize and conduct the focus groups and toprepare the data. We contracted Prairie Research

Associates Inc. (PRA) of Winnipeg to administer thetelephone survey.

The administrative data used in this study were

provided by the Saskatchewan Department of Health.The interpretations and conclusions contained herein donot necessarily represent those of the Government of

Saskatchewan or the Saskatchewan Department ofHealth. The telephone survey and focus group discussionwere supported by the Health Transition Fund, Health

Canada. The views expressed herein do not necessarilyrepresent the official policy of Health Canada.

References

American Hospital Association. (1989). Rural hospital closure:

Management and community implications. (pp. 34–35).

Chicago, IL: American Hospital Association.

Anderson, G. M. (1997). Hospital restructuring and the

epidemiology of hospital utilization: Recent experience in

Ontario. Medical Care, 35, OS93–OS101.

Bindman, A. B., Keane, D., & Lurie, N. (1990). A public

hospital closes. Impact on patients’ access to care and health

status. JAMA, 264, 2899–2904.

Burda, D. (1992). Hospital closures aren’t closing off access to

care. Modern Healthcare, 22, 18–20.

Cohen, M. M., & MacWilliam, L. (1995). Measuring the wealth

of the population. Medical Care, 33(12), D521–D542.

Fleming, S. T., Williamson Jr., H. A., Hicks, L. L., & Rife,

I. (1995). Rural hospital closures and access to services.

Hospital and Health Services Administration, 40,

247–262.

Hart, L. G., Pirani, M. J., & Rosenblatt, R. A. (1991). Causes

and consequences of rural hospital closures from the

perspective of mayors. Journal of Rural Health, 7, 222–245.

Health Services Utilization and Research Commission.

(1994). Barriers to community care. Health Services

Utilization and Research Commission, Saskatoon,

Canada.

Health Services Utilization and Research Commission. (2000).

The impact of preventive home care and seniors housing on

health outcomes. Health Services Utilization and Research

Commission, Saskatoon, Canada.

Hendricks, A, & Alberts, D. (1989). Closures of hospitals

between 1980 and 1987. Center for Health Economics

Research, Needham, MA. Contract Report Prepared for

the Health Care Financing Administration, U.S. Depart-

ment of Health and Human Services, Rockwille, MD.

James, A. M. (1999). Closing rural hospitals in Saskatchewan:

On the road to wellness?. Social Science and Medicine, 49,

1021–1034.

Kahn, H. A., & Sempos, C. T. (1989). Statistical methods in

epidemiology. New York: Oxford University Press.

McKay, N. L., & Coventry, J. A. (1995). Access implications of

rural hospital closures and conversions. Hospital and Health

Services Administration, 40(2), 227–246.

Morrison, D. F. (1976). Multivariate statistical methods. New

York: McGraw-Hill.

Mullner, R., & McNeil, D. (1986). Rural and urban hospital

closures: A comparison. Health Affairs, 5, 131–141.

Muus, K. J., Ludtke, R. L., & Gibbens, B. (1995). Community

perceptions of rural hospital closure. Journal of Community

Health, 20, 65–73.

Roos, N. P., & Shapiro, E. (1995). Using the information

system to assess change: The impact of downsizing the acute

sector. Medical Care, 33(12), DS109–DS126.

Rosenbach, M. L., & Dayhoff, D. A. (1995). Access to care in

rural America: Impact of hospital closures. Health Care

Financing Review, 17, 15–37.

Samuels, S., Cunningham, J. P., & Choi, C. (1989). The impact

of hospital closures on travel time to hospitals. Inquiry, 28,

194–199.

SAS Institute Inc. (1989). SAS/STAT user’s guide, version 6,

vol. 2, 4th ed., (846pp.). Cary, NC: SAS Institute Inc.

Shapiro, E., Tate, R. B., Wright, B., & Plohman, J. (2000).

Changes in the perception of health care policy and delivery

among Manitoba elders during the downsizing of the

hospital sector. Canadian Journal of Aging, 19, 18–34.

Stabler, J. C., & Olfert, M. R. (1996). The changing role of rural

communities in an urbanizing world: Saskatchewan, an update

to 1995. Canadian Plains Research Centre, University of

Regina. Regina, Canada.

Statistics Canada. (1995). National population health survey.

Statistics Canada, Ottawa, Canada. http://www.stats.-

gov.nt.ca/statinfo/health/nphs/nphs.html.


The Task Force on Municipal Legislative Renewal. (2000).

Interim Report of the Task Force on Municipal LegislativeRenewal. Regina, Canada. http://www.municipal.gov.sk.ca/

roundtable/intreportdoc.pdf.

The World Health Organization. (2000) Health for all in the

twenty-first century. http://www.who.org/.

U.S. Congress, General Accounting Office. (1991a). Rural

hospitals: Federal efforts should target areas where closures

would threaten access to care. Report to congressional

requesters (GAO-HRD-91–41). Washington, DC: US Gov-

ernment Printing Office.

U.S. Congress, General Accounting Office. (1991b) Rural

hospitals: Closures and issues of access (GAO-HRD-

91-46) (P. 1). Washington, DC: U.S. Government Printing

Office.

U.S. Department of Health and Human Services, Office of

Disease Prevention and Health Promotion. (2000). Amer-

ican healthy people 2010. http://web.health.gov/healthy-

people/Document/default.htm

U.S. Department of Health and Human Services, Office of the

Inspector General. (1989). Hospital Closure: 1987. Wa-

shington, DC: Office of the Inspector General.


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