When It Comes to Health Care Access, More Isn’t Always Better

Hospitals and policymakers routinely face a difficult question when investing in specialized emergency services: Will adding another facility improve care, or would those resources do more good somewhere else?

New UC San Francisco research suggests the answer depends heavily on what people already have access to. In nearly 600,000 California heart attack patients, survival rates improved after specialized services opened in communities that previously lacked timely access. But where those services were already available, opening another facility increased access only slightly and did not improve survival rates.

The findings highlight the importance of how limited health care resources are distributed. Adding capacity can produce significant benefits when it closes a critical access gap, the researchers found, while expanding services in communities that are already well served may do little to improve patient outcomes.

“Americans tend to think more is better, but where you put these services really matters,” said Renee Y. Hsia, MD, MSc, a UCSF professor of emergency medicine and senior author of the study. “Think of gas stations, for example. Adding another one in a neighborhood that already has five might make things a little more convenient. But if you put a gas station in an area where people previously had to drive 30 miles to find one, you’re meeting a real need. With emergency care, filling that gap can save lives.”

The researchers examined access to percutaneous coronary intervention (PCI), a procedure that restores blood flow through blocked arteries and can be lifesaving for patients experiencing a heart attack. Providing PCI requires hospitals to invest in specialized facilities, equipment, and personnel.

The study, published in JAMA Network Open, analyzed 590,282 heart attack hospitalizations in California between 2011 and 2022. Researchers examined what happened after a PCI-capable facility opened within a 30-minute drive, comparing communities that previously had timely access to PCI with those that did not.

In communities without prior access, a new facility was associated with a 53% relative increase in admission to a hospital capable of performing PCI and a 16% increase in patients receiving the procedure. Thirty-day mortality declined 20%, and one-year mortality declined 15%.

By contrast, in communities where PCI was already available within 30 minutes, opening another facility increased admission to a PCI-capable hospital by just 2% and use of the procedure by 3%. There was no significant change in mortality.

The access gap was particularly pronounced in rural California. Of the 52,756 heart attack patients from rural communities in the study, 81% lived in places without a PCI-capable facility within 30 minutes at the beginning of the study.

The findings build on previous research by Hsia and colleagues examining what happens when hospitals add capacity for specialized procedures.

An earlier study found that the number of PCI procedures performed in a community increased 7.5% after a new facility opened. The increase was nearly 20% in communities that previously lacked timely access, compared with about 8% in communities where PCI was already available.

The new research asks the next question: Does that additional capacity translate into better outcomes? That distinction matters because decisions about where to establish specialized services are often influenced by market demand, procedure volume, and hospitals’ expected return on investment. Those forces may not direct new services to communities where they can produce the greatest population health benefit, the researchers said.

“When we invest millions of dollars in specialized health care infrastructure, the question shouldn’t just be whether we can provide more services,” Hsia said. “We should be asking where those services will do the most good. We want to expand access, but we need to expand it wisely.”

Authors: The study was conducted by Yu-Chu Shen, PhD, of the Naval Postgraduate School and National Bureau of Economic Research, and Renee Y. Hsia, MD, MSc, of UCSF.

Funding: The study was supported by the National Heart, Lung, and Blood Institute (R01HL134182).

Disclosures: Hsia reported receiving grants from the National Institute on Minority Health and Health Disparities and the National Institute on Aging outside the submitted work. Shen reported receiving grants from the National Institute on Minority Health and Health Disparities and the Defense Health Agency outside the submitted work.