—We are happy to clarify our conclusions. Technical quality of care is one aspect of hospital performance, and small rural hospitals can provide basic services in a convenient, friendly setting. In addition, despite their lower occupancy, smaller hospitals provided care at lower cost than did larger urban hospitals.1 One might also question how much should be spent on aggressive treatment for these very sick patients. However, our study showed that these potential benefits of rural hospitals have a cost in terms of both reduced technical quality and increased death rates for patients with severe disease. Mr Behringer's letter notes that these problems are being addressed. We hope so.Dr Rosenblatt's references document that without access to hospital care, people's health suffers. However, many small hospitals struggle on despite low occupancy caused by competition with other nearby hospitals. Some of these hospitals could be transformed into other health
Keeler EB, Kahn KL. Quality of Care in Rural Hospitals-Reply. JAMA. 1993;269(7):866–867. doi:10.1001/jama.1993.03500070045016
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