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INTRODUCTION – Health systems are increasingly under pressure to do more with less, and policymakers around the world are faced with the challenge of improving both coverage and efficiency. Hospitals are under particular pressure as they are the default providers of emergency cover. Individuals often resort to hospital emergency departments not only for unavoidable or high-complexity emergencies but also for low-complexity cases that reflect unmet demand in other layers of the health system. A response to this situation has been to strengthen primary and ambulatory care and other rearguard non-hospital services, but there is still fairly limited evidence of the extent to which this lowers the pressure on hospitals and improves population-level health outcomes. As we move forward into an era with populations continuing to age, with rising medical costs and the impositions of fiscal austerity, the need for such evidence is pressing.

In this paper we assess the impacts of the opening of Urgent Care Centers (Unidades de Pronto Atendimento henceforth UPA) in the state of Rio de Janeiro in Brazil, on hospital caseload, hospital performance, population-level health outcomes, and service diversion. The existing evidence on access to urgent care centers and hospital emergency rooms focuses on facility level outcomes, typically hospital outcomes. We provide a more comprehensive analysis of hospital outcomes, but our our main contribution is that we assess displacement by investigating service diversion and by analysing population-level outcomes by facility type and at the regional level. Therefore we are able to uncover displacement and characterize effects through local health systems.

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