Patients at small, isolated, rural hospitals in US more likely to receive lower quality of care

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.

"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 study appears in the July 6, 2011, Journal of the American Medical Association (JAMA).

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."