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Small, isolated, rural hospitals show poorer results on measures of quality of care, patient outcomes

Posted Jul 05 2011 4:11pm
In the first national study to examine care at critical access hospitals (CAHs) in rural areas of the U.S., Harvard School of Public Health (HSPH) researchers found that CAHs have fewer clinical capabilities, lower quality of care, and worse patient outcomes compared with other hospitals. The researchers found that patients admitted to a CAH for heart attack, congestive heart failure, or pneumonia were at greater risk of dying within 30 days than those at other hospitals. The study shows that despite more than a decade of policy efforts to improve rural health care, substantial challenges remain.

In an analysis of data from more than 4,500 hospitals that serve Medicare beneficiaries, critical access hospitals (CAHs; no more than 25 acute care beds, located more than 35 miles from the nearest hospital) had fewer clinical capabilities, worse measured processes of care and higher rates of death for patients with heart attack, congestive heart failure or pneumonia, compared to non-CAHs, according to a study in the July 6 issue of JAMA .

"Critical access hospitals play an important and unique role in the U.S. health care system, caring for individuals who live in rural areas and who might otherwise have no accessible inpatient care," according to background information in the article. "The CAH designation was created with the goal of ensuring 'proximate access' to basic inpatient and emergency care close to home for approximately 20 percent of the U.S. population that still lives in rural communities. Despite broad policy interest in helping CAHs provide access to inpatient, care, little is known about the quality of care they provide.

Karen E. Joynt, M.D., M.P.H., of the Harvard School of Public Health, Boston, and colleagues conducted a study to examine CAHs' clinical and personnel resources, the quality of care they deliver, and their patients' outcomes. The analysis included 4,738 U.S. hospitals of Medicare fee-for-service beneficiaries with acute myocardial infarction (AMI) (10,703 for CAHs vs. 469,695 for non-CAHs), congestive heart failure (CHF) (52,927 for CAHs vs. 958,790 for non-CAHs), and pneumonia (86,359 for CAHs vs. 773,227 for non-CAHs) who were discharged in 2008-2009.

The researchers found that compared with other hospitals (n = 3,470), 1,268 CAHs (26.8 percent) were less likely to have intensive care units (380 [30.0 percent] vs. 2,581 [74.4 percent], cardiac catheterization capabilities (6 [0.5 percent] vs. 1,654 [47.7 percent], and at least basic electronic health records (80 [6.5 percent] vs. 445 [13.9 percent]).

For patients admitted with AMI, CAHs provided care that was concordant with Hospital Quality Alliance process measures 91.0 percent of the time compared with 97.8 percent of the time for non-CAHs. The difference was larger for CHF (80.6 percent vs. 93.5 percent) and smaller but still significant for pneumonia (89.3 percent vs. 93.7 percent).

Patients admitted to CAHs had higher 30-day risk-adjusted mortality rates for all 3 conditions than patients admitted to non-CAHs. Patients admitted to CAHs had 7.3 percent higher absolute 30-day mortality rates for AMI (23.5 percent vs. 16.2 percent; 2.5 percent higher mortality rates for CHF (13.4 percent vs. 10.9 percent; and 2 percent higher mortality rates for pneumonia (14.1 percent vs. 12.1 percent) than those admitted elsewhere.

"Despite more than a decade of concerted policy efforts to improve rural health care, our findings suggest that substantial challenges remain. Although CAHs provide much-needed access to care for many of the nation's rural citizens, we found that these hospitals, with their fewer clinical and technological resources, less often provided care consistent with standard quality metrics and generally had worse outcomes than non-CAHs," the authors write.

"… these findings should be seen as a call to focus on helping these hospitals improve the quality of care they provide so that all individuals in the United States have access to high-quality inpatient care regardless of where they live.

"Critical access hospitals face a unique set of obstacles to providing high quality care, and our findings suggest that their needs are not being met by current health policy efforts," said Karen Joynt, a research fellow in HSPH's Department of Health Policy and Management and the lead author of the paper.

The government defines CAHs as geographically isolated facilities with no more than 25 acute care beds. More than a quarter of acute care hospitals in the United States have been designated CAHs by the Medicare Rural Hospital Flexibility Program of the 1997 Balanced Budget Act. The program created payment reform that has kept small rural hospitals financially solvent, preserving access to care for rural Americans who might otherwise have no accessible inpatient provider.

Joynt and her colleagues analyzed the records of 2,351,701 Medicare fee-for-service beneficiaries at 4,738 hospitals (26.8 percent of which were CAHs) diagnosed with acute myocardial infarction (heart attack), congestive heart failure, and pneumonia in 2008-2009. Compared with other hospitals, CAHs were less likely to have intensive care facilities, advanced cardiac care capabilities, or even basic electronic health records. These hospitals were less likely to provide appropriate evidence-based care, as measured by the Hospital Quality Alliance metrics.

Patients admitted to CAHs had 30 to 70 percent higher odds of dying within 30 days after being admitted for heart attack, congestive heart failure or pneumonia. "We were surprised at the magnitude of these findings," said Ashish Jha, senior author on the study and an associate professor in HSPH's Department of Health Policy and Management. "These findings suggest that we need to redouble our efforts to help these hospitals improve."

"To improve the quality of care patients receive at CAHs, policy makers could explore partnerships with larger hospitals, increasing use of telemedicine, or inclusion of these hospitals in national quality improvement efforts," said Joynt. "Helping these hospitals improve is essential to ensuring that all Americans receive high-quality care, regardless of where they live."

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Study authors included Yael Harris, director of the Office of Health IT & Quality at the U.S. Department of Health and Human Services and E. John Orav, associate professor in the Department of Biostatistics at HSPH.

"Quality of Care and Patient Outcomes in Critical Access Rural Hospitals," Karen E. Joynt, Yael Harris, E. John Orav, Ashish K. Jha, Journal of the American Medical Association, July 6, 2011.


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