Rural Hospital Closures and Mortality From Time-Sensitive Conditions in Texas

Importance: Rural hospital closures in the US have accelerated since 2010, with Texas experiencing more rural closures than any other state. Whether closures are associated with population-level mortality remains unclear, and rural hospital closures in Texas have not been examined. Objective: To examine the association between rural hospital closures in Texas and county-level mortality from 4 time-sensitive conditions: acute myocardial infarction, stroke, sepsis, and asthma or chronic obstructive pulmonary disease. Design, Setting, and Participants: This county-year cohort study of Texas counties used 2 complementary difference-in-difference study designs with data from January 1, 2006, to December 31, 2019. Statistical analyses were performed from November 2025 to June 2026. Exposure: Residence in a county where a rural hospital closed or in the nearby affected area, assessed using 2 designs: adjacent-county exposure (a closure county or a county bordering a closure county) and Hospital Service Area (HSA)-based exposure (a county being within an HSA where a closure occurred). Main Outcomes and Measures: The main outcome was annual deaths per 100 000 residents from time-sensitive conditions (acute myocardial infarction, stroke, sepsis, and asthma or chronic obstructive pulmonary disease). County-level mortality rates were compared for treated and control counties for 3 to 5 years before and after closure. Regressions were adjusted for county fixed effects, year fixed effects, and time-varying sociodemographic county characteristics. Results: In the sample of 175 counties (71 treated and 104 control counties in the adjacent-county design and 53 treated and 122 control counties in the HSA treatment design), 14 rural hospitals (approximately 8% of rural hospitals in Texas) closed during the study period. Closures were associated with 12 additional annual time-sensitive deaths per 100 000 residents in an affected county (adjacent-county treatment: average treatment effect on the treated [ATT], 11.60 [95% CI, 4.62-18.58]; P = .001; HSA treatment: ATT, 11.52 [95% CI, 0.46-22.58]; P = .04). This represented a 5.4% increase compared with the baseline mortality rate in affected counties. Estimates were robust to several sensitivity analyses. Supplementary analyses suggested that mortality associations were concentrated in acute emergencies, persisting under an alternate definition of time-sensitive conditions (adjacent-county ATT, 8.21 [95% CI, 2.08-14.34] per 100 000 residents) but not under a broader definition (adjacent-county ATT, 6.85 [95% CI, -2.31 to 16.01] per 100 000 residents). Conclusions: In this cohort study, rural hospital closures in Texas were associated with increased population-level mortality from time-sensitive conditions. The findings suggest that there were adverse patient outcomes in the aftermath of rural hospital closures, emphasizing a need to manage the emergency response and the progressive deterioration of clinical infrastructure and patient health.