Background: Service reconfigurations sometimes increase travel time and/or distance for patients to reach their nearest hospital or other urgent and emergency care (UEC) facility. Many communities value their local services and perceive that proposed changes could worsen outcomes for patients.
Objectives: To identify, appraise and synthesise existing research evidence regarding the outcomes and impacts of service reconfigurations which increase the time and/or distance for patients to reach an urgent and emergency care facility. We also aimed to examine available evidence regarding associations between distance to a facility and outcomes for patients and health services, together with factors which may influence (moderate or mediate) these associations.
Methods: We searched seven bibliographic databases in February 2019. The search was supplemented by citation tracking and reference list checking. A separate search was conducted to identify current systematic reviews of telehealth to support UEC.
Brief inclusion and exclusion criteria were as follows:
• Population: Adults or children with conditions that required emergency treatment
• Intervention/comparison: Studies comparing outcomes before and after a service reconfiguration which affects time/distance to UEC or comparing outcomes in groups of people travelling different distances to access UEC
• Outcomes: Any patient or health system outcome
• Setting: UK and other developed countries with relevant healthcare systems
• Study design: Any.
The search results were screened against the inclusion criteria by one reviewer, with a 10% sample screened by a second reviewer. Quality (risk of bias) assessment was undertaken using The Joanna Briggs Institute Checklist for Quasi-Experimental Studies. We performed a narrative synthesis of the included studies and assessed overall strength of evidence using a previously published method
Results: We included 44 studies in the review, of which eight originated from the UK. For studies of general UEC populations, there was no evidence that reconfiguration resulting in increased travel time/distance affected mortality rates. By contrast, evidence of increased risk was identified from studies restricted to patient s with acute myocardial infarction (AMI). Increases in mortality risk were most obvious within the first 1 to 4 years after reconfiguration. Evidence for other conditions was inconsistent or very limited. In the absence of reconfiguration, evidence mainly from cohort studies indicated that increased travel time or distance is associated with increased mortality risk for the acute MI and trauma populations, whereas for obstetric emergencies the evidence was inconsistent.
We included 12 systematic reviews of telehealth. Meta-analyses suggested that telehealth technologies can reduce time to treatment for people with stroke and ST elevation MI.
Limitations: Most studies came from non-UK settings and may were at high risk of bias because of no true control group. Most review processes were carried out by a single reviewer within a constrained timeframe.
Conclusions: We found no evidence that increased distance increases mortality risk for the general population of people requiring UEC, although this may not be true for people with acute MI or trauma. Increases in mortality risk were most likely in the first few years after reconfiguration.
Future work: Research is needed to better understand how health systems plan for and adapt to increases in travel time; to quantify impacts on health system outcomes; and to address uncertainty about how risk increases with distance in circumstances relevant to UK settings.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)