Main findings
This systematic review addressed the effect of increasing distance to UEC on patient and health system outcomes by looking at two main groups of studies. In relation to the first research question (What is the evidence regarding effects on patients of service reconfigurations which increase the time/distance to an UEC facility?), the reconfiguration studies found no evidence that increasing travel time or distance increased mortality risk for general populations of patients attending UEC facilities. There was some evidence from studies that were restricted to patients with AMI of an increased risk of mortality, whereas evidence for other conditions was inconsistent or very limited.
The association studies addressed the second research question (What is the evidence regarding associations between time/distance from an UEC facility and outcomes for patients requiring UEC?). These studies found evidence of an association between distance and mortality for general, AMI and trauma populations, whereas evidence for maternity was inconsistent. Pregnant women differ from other populations requiring emergency care in that their period of highest risk is finite and predictable. In some health systems, primarily those with potentially very long travel distances or times, this risk can be mitigated by the option of temporary relocation closer to a specialist unit.6,39
Telehealth care is clearly the most important intervention for mitigating the effects of distance from specialist emergency care. Because of the large volume of available research, we performed a narrative overview of recent systematic reviews (see Chapter 4). Telehealth technology mitigates distance effects by facilitating access to clinical expertise and/or by speeding up treatment, as demonstrated in two meta-analyses.48,54 Although we did not formally assess the quality of the included reviews, review quality was clearly variable and most of the reviews used a mapping or narrative synthesis approach. Telehealth is most strongly established as an intervention for timely treatment of stroke patients.51 Telehealth technology in pre-hospital settings is relatively new and included reviews have identified a range of barriers to adoption and questions about how best to implement the technology.58,59 None of the systematic reviews focused on cost-effectiveness, which has been a barrier to the adoption of telehealth in some UK settings.
Much of the research included in our review comes from non-UK settings and we have endeavoured to keep applicability in mind throughout. Absolute distances and times of travel vary within countries, including the UK, but large countries such as the USA, Canada and Australia are likely to have longer travel times/distances on average outside urban areas. This is also true for some of the Scandinavian countries where travel times can be long as the population is centred in fewer areas, meaning that remote communities have less access to UEC.
Several included studies suggest that the effects of service reconfiguration on outcomes, particularly patient outcomes, may be short-lived, with health systems adapting to the new situation over a few years. In the study by Avdic,5 effects of ED closures on AMI mortality were statistically significant only for the first year after closure, while Shen and Hsia12 identified a 4-year transition period. Some studies reported on efforts by health-care commissioners and providers to mitigate the effects of reconfiguration. Avdic5 mentioned increased investment in both emergency service provision and prevention although the study did not evaluate whether or not these actually occurred. A hospital in Boston, USA, provided early notice of its intention to close an ED and worked closely with EMS providers to minimise the effect on the EMS system in the city.7 Yaghoubian et al.14 also in the USA, reported on changes in trauma centre staffing and organisation to prepare for the closure of a nearby centre. The limited insights provided by these studies emphasise the need for greater understanding of how health service stakeholders prepare for the system-wide impacts of changes that require patients to travel further for treatment, as also mentioned by Knowles et al.2
We identified a large number of potential mediating, moderating and mitigating factors (see Figure a and Appendix 4). The extent to which these factors occur and their amenability to modification by health system interventions is highly variable. Most of the included studies adjusted for the influence of common moderators and mediators in their statistical analysis, which provides reasonable confidence in the observed associations between travel distance/time and patient outcomes. However, an influence of confounding factors not allowed for in authors’ analyses and statistical models cannot be ruled out.
Service reconfigurations are often supported by decision-makers on the grounds that increased patient volume and/or specialisation in a smaller number of UEC facilities will increase the quality of patient care overall. This review did not directly address the relationship between volume and outcomes, which has been the subject of a large volume of research. However, one included study14 attributed successful adaptation to a trauma centre closure partly to staff gaining experience from treating more patients during the study period. We also note that there is substantial evidence for the benefits of transporting patients with stroke or severe trauma to specialist centres, often bypassing nearer non-specialist facilities. Studies included in this review identified benefits of transport to a PCI-capable hospital for patients with AMI, particularly STEMI.22–24
Interpretation of the findings of included studies should be guided by the quality and strength of the included evidence. We have assessed risk of bias at the level of the individual study and overall strength of evidence for key findings using a scheme successfully employed in previous reviews. Many of the included studies were judged to be at relatively high risk of bias because of their observational design and the absence of an independent control group in many cases. On the positive side, most studies acknowledged and attempted to adjust for the influence of confounding factors and some were large and/or long term. Furthermore, studies using routinely collected data may reflect real clinical practice more accurately than those involving carefully selected and knowingly recruited research participants. In view of this uncertainty, we have been relatively conservative in assessing the overall strength of evidence for effects and associations (see Tables 15–18).
Strengths and limitations
This systematic review was undertaken by an experienced team including both methodological and topic experts. We followed a protocol developed in collaboration with the National Institute for Health Research (NIHR) HSDR programme team as the review was designed in part to help clarify research priorities. The protocol was registered prospectively with the PROSPERO database of systematic review protocols (registration number CRD42019123061).
We performed a thorough search for published literature dating back to 2000 supplemented by citation-tracking of key studies and reference list checking of all included studies. This was clearly worthwhile as six included studies were identified by reference list checking and three by citation-tracking.
Resource constraints meant that we abbreviated the review process by using a single reviewer to perform study selection, quality assessment and data extraction, with checking of a 10% sample by a second member of the review team. This may be considered a limitation when measured against the gold standard of double independent performance of these stages but analysis of study selection revealed a high level of agreement among three reviewers. Although there is a risk of some errors or subjective assessments, we do not believe that these would have influenced the review’s main findings and conclusions.
The coverage of telehealth by an overview of relevant systematic reviews was partly determined by the limited available resources but we believe the decision was justified by the 12 largely recent systematic reviews included. The included reviews provide a thorough overview of this heavily researched field, using a mixture of quantitative (including meta-analysis) and narrative synthesis. It was encouraging that the reviews covered aspects of the implementation of telehealth58 as well as reviews of intervention effectiveness.
A strength of the review is that we approached the research question from two different angles, represented by the reconfiguration and association groups of studies. The reconfiguration studies address a dynamic situation where change to services has actually happened, while the association studies take a more static approach, examining how distance to UEC influences outcomes in a particular setting. Both groups of studies represent substantial bodies of research using different study designs and with largely complementary results. In the narrative synthesis, we considered these groups of studies (together with the mitigation and telehealth studies) separately but also assessed the body of evidence as a whole in relation to relevance to the UK and to rural settings. We have summarised the overall strength of evidence from the two main groups of studies using a published framework that we hope will be helpful for decision-makers needing a quick overview (see Tables 15–18).
We extracted details of moderating and mediating factors from the included studies, as summarised in Figure a. Figure a includes both factors that influence travel time and those that influence patient outcome (either alone or through interaction with time/distance). The figure is not comprehensive and the relative importance of different factors will vary between settings. In spite of this, the information in the figure and related appendix (see Appendix 4) may be of value to decision-makers by helping them to identify service factors that can be modified to enable faster access to treatment and potentially better outcomes.
The relationship between distance/time to emergency care and patient outcomes is clearly a complex one. The diverse measurement methods and outcomes in the included studies meant that we were unable to perform any meta-analyses to estimate pooled outcome measures across studies. Although this may be considered a limitation of the review, we did not have meta-analysis as one of our predefined objectives and any estimate would only be meaningful in the absence of major clinical and/or statistical heterogeneity. The summary table of association studies (see Table 19) illustrates the wide range of measures used in included studies and allows readers to identify studies relevant to their population and setting of interest.
Implications for service delivery
Timely and equitable access to UEC is important to all population groups in both urban and rural settings. Ensuring such access requires commissioners and providers of health services to work effectively together, informed by their understanding of the evidence and data relevant to their local context. As many of the studies included in this review demonstrate, the relationship between time or distance and outcomes is influenced by many factors, including patient characteristics, clinical care, geography and infrastructure.
Studies included in this review provide insight into issues that decision-makers may wish to consider and act on when reconfiguration that may affect access to UEC is under consideration. For England, Roberts et al.4 identified the following considerations for planners: size of population served, availability of specialist centres (e.g. for trauma, stroke), availability of workforce, organisation of training and whether or not there are sufficient ‘support facilities’. The authors also pointed out the need for political decisions at the national and local level about which services are affordable.
Empirical studies of the effects of ED closures and reconfigurations have provided insights into how change can be managed to minimise any adverse effects on patients or the stability of the wider health and care system. El-Sayed et al.7 noted the importance of early notification of planned closure and ‘continuous and dynamic co-operation’ between hospital and EMS administrations. Yaghoubian et al.14 prepared for closure of a nearby trauma centre by putting in place additional staffing and changes to team organisation. A strong regional trauma system also helped to ensure that remaining trauma centres were able to accommodate additional patients.
Several included studies suggest that the effects of increased travel distance/time on outcomes may be temporary, lasting 1 or a few years. The research suggests that health services may be able to minimise the transition period by measures such as investment in EMS5 and by providing capacity elsewhere before any closures take place.12 Studies also suggest that the scale of any changes in distance or time is important and small changes may have a minimal impact on outcomes at the population level.4,9 Service design needs to take into account the effects of distance on outcomes but also allow for the fact that rural and remote areas are less densely populated than towns and cities, resulting in lower demand/need for services. The benefits to individuals of having services located close by have to be balanced against overall population benefits that may accrue from centralisation of services and concentration of expertise at selected sites.
Another approach to handling increased distance to UEC facilities is through new service delivery models. This review has identified a number of different models that decision-makers may wish to consider. In the maternity setting, some health-care systems provide the option for women from more remote regions to travel to a more central facility for a short period before the expected date of delivery.6 Service models based on telehealth have been extensively researched, as covered in Chapter 4. For example, telehealth technologies may enable EDs in rural and remote areas to be run on a ‘hub-and-spoke’ model, with less critical emergencies being handled by nurses with remote clinical support.55 The use of telehealth in ambulances allows service models based on early initiation of diagnosis and/or treatment by paramedics as well as triage to divert less seriously ill patients away from EDs when clinically appropriate.52,58,59 However, barriers remain to the widespread adoption of telehealth technology in some settings. Other mitigation interventions, including improved co-ordination between services,46 are discussed in the relevant sections of Chapter 3 (see Mitigation studies).
Some service models that may be of interest to decision-makers fell outside the scope of this review (e.g. air ambulance services) or were excluded after full consideration (e.g. public access defibrillators). We did not identify any evaluations of community first responders, although this service is available in many parts of the UK. Descriptions of the service suggest that first responders may be of most value for conditions such as cardiac arrest for which distance to the nearest UEC facility is unlikely to influence survival.
Although increased distance to UEC is generally discussed in terms of possible risks, included studies also suggested some potential benefits to patients and the health system. EDs may close or be downgraded for reasons to do with quality of care,2,9 potentially encouraging patients to use superior services. Reconfiguration of services may encourage EDs and other centres to organise their work more efficiently and a greater volume of patients may enable staff to improve the quality of the care they deliver through increased experience.14 This aspect is reflected most clearly in the increasing trend to transport patients to specialist centres, especially for stroke and trauma, rather than to closer but less specialised facilities.
Two studies from Scandinavia provide further insights into the effects of UEC service reconfigurations on the wider health and care system. In Denmark, Hansen et al.8 reported that EDs up to 40 km away were able to compensate, at least in part, for closure of a local ED. However, the authors noted that this was dependent on free and rapid access to ambulance services and high levels of car ownership. A controlled before–after study in Finland reported that closure of a local primary care ED decreased use of ED services in nearby areas without increasing use of other office-hour services.11 The authors concluded that distance is an important influence on ED attendance and ED closure can be used to encourage patients to access care via other routes. Differences between the primary care-based ED system in Finland and that of the UK should be taken into account when considering this evidence.
Despite these caveats, the review provides some evidence that closing EDs may reduce self-presentation at an ED by patients who could be treated elsewhere. The relationship between distance and ED attendance in the UK was studied by Rudge et al.,21 who found that the availability of a MIU nearby reduced ED use by those living at a distance from an ED. This suggests that if alternatives can be put in place, there will not necessarily be a commensurate increase in workload for an ED if a neighbouring ED closes. Effects on patient flow could be taken into account at an early stage of planning for possible service reconfigurations.
Studies included in this review illustrate the importance of up-to-date research and evidence to inform decision-making. An example is the care of patients with AMI, where PCI is now the therapy of choice in most regions. This implies the need for health systems to monitor the long-term effects of service reconfigurations as they become mature and to account for other innovations which may ultimately offset any disadvantages from having to travel further.
There is a consistent message from both UK and international research about the importance of considering the EMS implications of planned service changes.2,7,34 EMS staff cover the whole catchment area of a specialist service, meaning that increased travel distances result in increased job cycle times and more resources needed to maintain the same response to demand. The challenge for decision-makers is how to fund and staff the service while also using EMS staff in a wider variety of roles (e.g. treating more patients at the scene rather than transporting them to hospital).
Health services need to ensure that increases in time or distance to UEC are not associated with increased health inequity. A large UK study suggested that there may be a risk of this.21 Rudge et al.21 found that ED attendance decreased as distance to the nearest ED increased but the effect was more notable in deprived areas than less deprived ones. Mustonen et al.11 also emphasised the importance of ensuring that UEC services are not located far away from socially deprived areas.
Finally, although the focus of this review is on UEC and other health services, actions taken elsewhere can influence distance/time to UEC and hence outcomes for patients. Examples include improvements to road networks and associated factors, such as junctions and lighting, as well as regulations surrounding alcohol and drug use by drivers (which, in turn, affect actual consumption).
Implications for research
We have identified the following implications for further research.
There is a need for further time series analyses along the lines of the closED study2 to examine the longer-term effects of service reconfigurations on the whole UEC system and to take into account the impact of other service and technological changes over time. Although such studies should ideally be controlled, uncontrolled time series also have some value and are easier to organise.
Research is needed to better understand how local and regional health systems plan for and adapt to increases in travel distance/time. As suggested by other researchers,2 this could take the form of qualitative research and/or documentary analysis. The current programme of service reconfiguration provides opportunities for prospective studies in a range of different settings. Research should aim to capture the perspectives of a range of different stakeholders including health professionals, managers in both commissioner and provider organisations and the general public.
Data analysis is needed to address uncertainty about how risk increases with distance/time within the range relevant to UK urban and rural populations. This could involve analysis of existing data or new research to ascertain whether or not the findings of earlier studies18,19 remain valid with current road conditions and technology.
Analysis of routine data to examine whether UEC reconfigurations reduce overall demand for ED care or merely displace demand to other parts of the health-care system. Data can also be used to examine the nature and extent of variation between different localities with a view to reducing unnecessary variation and improving overall quality of care.
Research is needed to assess patient outcomes other than mortality and hospital admission/length of stay. This could include effects of service reconfiguration on families who may incur additional social and financial costs because of increased travel distance/time to visit patients.
Public attitudes to reconfiguration and involvement in decision-making were outside the scope of this review. Nevertheless, it is clear that proposals to reconfigure UEC services are often opposed by local communities based on concerns that increased travel distance/time may increase the risk of adverse outcomes. Further research would be valuable to understand public attitudes to risk and preferences for different alternatives. Research could involve a variety of methods including consultation via citizens’ assemblies or similar.
Conclusions
This systematic review found no evidence that service changes that increased average travel time or distance increased mortality risk for general populations of patients attending UEC facilities. There was some evidence of an increased risk from studies restricted to patients with AMI, whereas evidence for other conditions was inconsistent or very limited. Studies that examined the association between distance and outcomes in the absence of reconfiguration found evidence of an association between distance and mortality for general, AMI and trauma populations, whereas evidence for maternity was inconsistent. The relatively low quality of much of the research suggests that findings should be interpreted cautiously. In particular ‘no evidence of increased risk’ does not necessarily mean ‘evidence of no increase in risk’, as the finding could be overturned by further research in the future.
Empirical studies of the effects of ED closures and reconfigurations have provided insights into how change can be managed to minimise any adverse effects on patients or the stability of the wider health and care system. Important factors include early notification and discussion of planned changes, co-operation between different stakeholders, and appropriate changes to staffing and organisation of the workforce. Several included studies suggest that the effects of increased travel distance/time on outcomes may be temporary, lasting one or a few years. Health-care services may be able to minimise the transition period by measures such as investment in EMS and by providing capacity elsewhere before any closures take place.
There is a consistent message from both UK and international research about the importance of considering the EMS implications of planned service changes. We also found evidence that people in more deprived areas were less willing/able to travel to attend an ED. This suggests that consideration should be given to ensuring that UEC services are not located far away from socially deprived areas.
Research priorities include work to examine the longer-term effects of service reconfigurations on the whole UEC system and to better understand how local and regional health-care systems plan for and adapt to increases in travel distance/time.