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October 19, 2011

Quality of Care in Critical Access Hospitals

Author Affiliations

Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

Author Affiliations: Yuma District Hospital, University of Colorado, Denver (Dr Westfall) (; VA Eastern Colorado Health Care System, University of Colorado, Denver (Dr Battaglia); and Colorado Rural Health Center, Aurora (Ms Mills).

JAMA. 2011;306(15):1653-1655. doi:10.1001/jama.2011.1488

To the Editor: The study by Dr Joynt and colleagues on patient outcomes in rural CAHs1 failed to account for several factors in their methods, analysis, and interpretation. Patients transferred from the emergency department (ED) of a CAH were not included. Approximately 20% to 25% of all patients with AMI are transferred directly from the ED.2 Patients transferred directly from the ED are not counted as index admissions at that hospital. Transferred patients are significantly younger and have fewer comorbid conditions and better clinical outcomes, enriching the accepting hospital data and removing this cohort of patients with better outcomes from the CAH data.3,4 Emergency department transfers may have accounted for the variation in reported outcome between CAHs and non-CAHs for AMI and pneumonia. In contrast to AMI, few pneumonia patients are transferred directly from the ED, so they remain in the CAH data. For AMI, the adjusted odds ratio was 1.14 (95% CI, 1.05-1.24). For pneumonia, the adjusted odds ratio was not statistically significantly increased at 1.05 (95% CI, 0.99-1.11). In addition, in a CAH, identifying patients most likely to benefit from transfer is an essential skill and may be an important quality indicator. In this analysis, CAHs got no credit for high-quality ED transfer.