Author Affiliations: Department of Community and Family Medicine, University of Illinois College of Medicine at Rockford (firstname.lastname@example.org).
In Reply: We agree with Dr Fairchild about the importance of evaluating rural CAHs in the context of their resources and community setting. As Fairchild suggests, selection bias and the community setting might account for some of the differences in outcomes reported by Joynt et al.1 Patients at CAHs mirror the demographics of rural communities where residents are older, sicker, and more likely to engage in unhealthy behaviors when compared with their nonrural counterparts. As Fairchild notes, other factors such as cultural expectations may also contribute to differences in outcomes. Although assessing differences in care between rural and urban settings remains challenging, our belief is that research that stimulates thoughtful discussion about quality ultimately leads to better care.
Lipsky MS, Glasser M. Quality of Care in Critical Access Hospitals—Reply. JAMA. 2011;306(15):1653-1655. doi:10.1001/jama.2011.1491