Critical access hospitals provide lower quality of care

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.

The findings of this study should serve as a stimulus to explore strategies on how to improve quality and outcomes for those patients receiving care at a CAH, according to Martin S. Lipsky, M.D., and Michael Glasser, Ph.D., of the University of Illinois College of Medicine at Rockford, in an accompanying editorial.

"The national translational research agenda should include research that focuses on how to adapt best practices to rural settings. Academic health partnerships that prepare health professionals for careers in rural settings and explore how to collaborate with rural hospitals to use technological solutions such as telemedicine, e-ICUs, and e-consults may be helpful."

"Although the differences in CAH outcomes may be accounted for by cultural, economic, and other environmental issues, this study should also serve as a challenge to improve the health care experienced by rural residents. All residents in the United States should have access to safe, high-quality health care and should have confidence in the health care system regardless of where they live."