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Original Contribution
July 6, 2011

Quality of Care and Patient Outcomes in Critical Access Rural Hospitals

Author Affiliations

Author Affiliations: Departments of Health Policy and Management (Drs Joynt and Jha) and Biostatistics (Dr Orav), Harvard School of Public Health, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (Drs Joynt, Orav, and Jha); Veterans Affairs Boston Healthcare System, Boston, Massachusetts (Dr Jha); and Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland (Dr Harris).

JAMA. 2011;306(1):45-52. doi:10.1001/jama.2011.902
Abstract

Context Critical access hospitals (CAHs) play a crucial role in the US rural safety net. Current policy efforts have focused primarily on helping these small, isolated hospitals remain financially viable to ensure access for individuals living in rural areas in the United States; however, little is known about the quality of care they provide or the outcomes their patients achieve.

Objectives To examine the quality of care and patient outcomes at CAHs and to understand why patterns of care might differ for CAHs vs non-CAHs.

Design, Setting, and Patients A retrospective analysis in 4738 US hospitals of Medicare fee-for-service beneficiaries with acute myocardial infarction (AMI) (10 703 for CAHs vs 469 695 for non-CAHs), congestive heart failure (CHF) (52 927 for CAHs vs 958 790 for non-CAHs), and pneumonia (86 359 for CAHs vs 773 227 for non-CAHs) who were discharged in 2008-2009.

Main Outcome Measures Clinical capabilities, performance on processes of care, and 30-day mortality rates, adjusted for age, sex, race, and medical comorbidities.

Results Compared with other hospitals (n = 3470), 1268 CAHs (26.8%) were less likely to have intensive care units (380 [30.0%] vs 2581 [74.4%], P < .001), cardiac catheterization capabilities (6 [0.5%] vs 1654 [47.7%], P < .001), and at least basic electronic health records (80 [6.5%] vs 445 [13.9%], P < .001). The CAHs had lower performance on processes of care than non-CAHs for all 3 conditions examined (concordance with Hospital Quality Alliance process measures for AMI, 91.0% [95% CI, 89.7%-92.3%] vs 97.8% [95% CI, 97.7%-97.9%]; for CHF, 80.6% [95% CI, 79.2%-82.0%] vs 93.5% [95% CI, 93.3%-93.7%]; and for pneumonia, 89.3% [95% CI, 88.6%-90.0%] vs 93.7% [95% CI, 93.6%-93.9%]; P < .001 for each). Patients admitted to CAHs had higher 30-day mortality rates for each condition than those admitted to non-CAHs (for AMI: 23.5% vs 16.2%; adjusted odds ratio [OR], 1.70; 95% confidence interval [CI], 1.61-1.80; P < .001; for CHF: 13.4% vs 10.9%; adjusted OR, 1.28; 95% CI, 1.23-1.32; P < .001; and for pneumonia: 14.1% vs 12.1%; adjusted OR, 1.20; 95% CI, 1.16-1.24; P < .001).

Conclusion Compared with non-CAHs, CAHs had fewer clinical capabilities, worse measured processes of care, and higher mortality rates for patients with AMI, CHF, or pneumonia.

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