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October 8, 2008

Comparisons of Safety-Net and Non–Safety-Net Hospitals

JAMA. 2008;300(14):1650-1652. doi:10.1001/jama.300.14.1651-a

To the Editor: In their study of safety-net and non–safety-net hospitals, Dr Werner and colleagues1 assert that both quality of care and the rate of improvement in safety-net hospitals are lower than in non–safety-net hospitals. I believe there are flaws in the study methodology and findings.

The authors identified a group of 928 “safety-net hospitals” based solely on the percentage of patients insured by Medicaid. This overly broad definition assesses small rural and large urban teaching hospitals equally even though they share few common characteristics. For example, rural hospitals do not operate large trauma centers characteristic of their urban counterparts, and they experience far smaller inpatient censuses. Yet the authors lump these dissimilar facilities together and claim that, because this ill-defined group is overrepresented in the bottom decile of performance and underrepresented in the top decile, all safety-net hospitals must be performing poorly.