Do patients receive worse care when they’re admitted to a critical access rural hospital? A new study suggests they do, and that these smaller hospitals not only have lower-quality processes of care and fewer resources but also have worse outcomes for their patients.
The study appears in the latest issue of the Journal of the American Medical Association. In a way, it’s ground-breaking. Although there’s been considerable research on the economics and the social impact of small rural hospitals, much less is known about the quality of care they provide.
The authors of the study analyzed Medicare data from more than 4,700 hospitals – both critical access and non-critical access facilities – for patients admitted with acute heart attack, congestive heart failure or pneumonia. They also collected information on patient and community demographics, hospital characteristics such as size and staffing levels, and reportable quality measures.
Among the findings:
– Critical access hospitals have fewer clinical resources than other hospitals and are more likely to be located in counties with fewer medical specialists.
– Critical access hospitals are less likely to have electronic medical records.
– These hospitals have lower performance on measures of quality care, even after adjusting for factors such as hospital characteristics and the patient case mix.
– Critical access hospitals have a higher 30-day mortality rate for acute heart attack, congestive heart failure and pneumonia than other hospitals.
The study’s authors reach a rather dispiriting conclusion:
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.
This is one way to spin the story. It’s not the only way, however.
What is the role, exactly, of the critical access hospital? Virtually all of these hospitals have fewer than 25 beds and are the only source of hospital care in their immediate community. Although a handful are located in suburbs or inner cities, the vast majority are in the rural United States.
Whether they provide quality care to patients is a valid and important question. If the question is going to be asked, however, it ought to be framed within the proper context.
In the JAMA study, one of the yardsticks against which critical access hospitals were measured was whether they had an intensive care unit, surgical capabilities or a cardiac catheterization lab. Is this a standard that’s realistic or even appropriate for smaller rural hospitals?
Comparisons also are challenging because of the characteristics that make small rural hospitals unique. It’s intuitive that they would have fewer clinical resources and less access to technology and specialized care. When you stack them against larger hospitals, the contrast is bound to be obvious, but these limitations are simply part of the terrain inhabited by critical access hospitals. Many critical access hospitals are very good at being exactly who they are – small rural critical access hospitals.
The authors of the JAMA study acknowledge another important point: The performance measures they analyzed were limited because many of the small rural hospitals either didn’t report the data or their sample size was too small.
For anyone who lives in a rural community or has ever been a patient at a critical access hospital, the findings of this study should trigger thoughtful discussion. Although the financial viability of small rural hospitals is important, policymakers and health care leaders ought to be placing more focus on quality of care and how this can be achieved at hospitals with limited resources. Better methods need to be developed for capturing performance data at facilities where patient numbers are small, and providing tools that help rural hospitals accurately and realistically benchmark how they’re doing. Perhaps even the definition of quality needs to be reshaped to better reflect the role and capabilities of the critical access hospital.
Finally, it seems the entire conversation about critical access hospitals is in need of reframing. There’s a lot of talk about what they aren’t. Perhaps we should be talking instead about what they are and how they can be supported, for the sake of their patients, to do their best as critical access hospitals.
Image: National Sunflower Association/Associated Press