Author Insights: Small Rural Hospitals Falling Behind on Mortality Rates Despite Federal Aid

Karen E. Joynt, MD, MPH, of Brigham and Women’s Hospital in Boston, and her colleagues found that mortality rates for certain conditions are increasing at some rural hospitals. Image: Harvard School of Public Health

Karen E. Joynt, MD, MPH, of Brigham and Women’s Hospital in Boston, and her colleagues found that mortality rates for certain conditions are increasing at some rural hospitals. Image: Harvard School of Public Health

Over the last decade, most acute care hospitals have been able to reduce 30-day mortality rates for patients with myocardial infarction, congestive heart failure, and pneumonia. But small rural hospitals participating in a federal program to increase rural access have seen their 30-day mortality rates for these conditions increase, according to a study published today in JAMA.

Millions of US residents live in rural areas with limited access to medical care. To secure better access to hospital care for these individuals, the US Congress created the critical access hospital (CAH) program in 1997. Hospitals with 25 or fewer beds that are at least 35 miles from an another source of care are eligible for the program and reimbursed by the government for the full cost of care they provide rather than the smaller proportion offered to typical hospitals. These CAHs also are exempt from certain federal hospital quality improvement initiatives.

The program has been popular, with about 1 in 4 US hospitals participating by 2010.

The program appears to have stemmed the tide of closures for small rural hospitals, but these facilities continue to face financial and staffing difficulties. Some data have also suggested they have worse patient outcomes. To better assess patient outcomes at CAHs as measured by trends in 30-day mortality, Karen E. Joynt, MD, MPH, of Brigham and Women’s Hospital in Boston, and her colleagues analyzed data for Medicare fee-for-service patients admitted to acute care hospitals between 2002 and 2010, including nearly 2 million patients admitted for myocardial infarction, about 4.5 million admitted for congestive heart failure, and nearly 4.5 million admitted for pneumonia. They found that death rates were comparable between CAHs and other hospitals for these conditions (12.8% vs 13%) in 2002, but by 2010, 30-day mortality rates had increased for patients with these ailments at CAHs (13.3%) while such rates had declined at non–critical access hospitals (11.4%). They found a similar divergence in death rates when they analyzed outcomes for each condition separately.

Dr Joynt discussed the findings with news@JAMA.

news@JAMA: Why did you decide to do this study?

Dr Joynt: Previously, we looked at CAHs vs non–critical access hospitals and saw differences  in quality of care and patient outcomes. We were interested in taking a look at the trajectory of patient outcomes over a longer period to give us insights on the impact of the CAH policy.

news@JAMA: What prompted the creation of the CAH program?

Dr Joynt: At the time it was created, a bunch of rural hospitals were closing. Basically, if one of these small hospitals had one really sick patient, it could wipe out their entire budget for a year. So in the CAH program, the hospitals are put in a special federal payment program that pays the full cost of patient care. They were exempted from public reporting of outcomes and pay-for-performance [criteria] with the thought that the administrative burden of these programs would be hard on these small institutions. On the financial side, the CAH program has been quite successful. There have been fewer rural hospitals closing, so it has done a good job of preserving access to care. But what hadn’t been looked at was the clinical outcomes at these hospitals over time.

news@JAMA: What do you think is driving the divergence of mortality rates between CAHs and non-CAHs?

Dr Joynt: One thing that may be contributing is that medicine is increasingly dependent on advanced technology and is increasingly centralized. It doesn’t make sense for a rural hospital with 10 beds to have the advanced equipment or the kind of 24-hour staffing that larger hospitals have. It may be hard for them to provide complex care. The rural population is also aging and has growing socioeconomic challenges. The fact that CAHs are not participating in national quality improvement efforts might also be contributing. An important piece of quality improvement is measuring outcomes, and small hospitals don’t always have the resources to track patient outcomes.

news@JAMA: Should these hospitals be required to participate in quality improvement initiatives?

Dr Joynt: It is important to track patient outcomes. It is difficult because rural hospitals may only have a small number of patients. Public reporting is tricky because of the small sample sizes, but it looks like approaching CAHs as a separate system hasn’t been optimal. Maybe there are different quality improvement fixes that would work at a small rural hospital.

news@JAMA: Do you think these hospitals are providing a lower quality of care?

Dr Joynt: I think it’s a systems problem, not a hospital problem. I don’t think the message should be that the CAH hospitals are providing bad care. I do think that these are some of the hardest-working people doing some of the most challenging jobs in medicine. But what we are asking rural hospitals to do without specialists and technology is impossible. It’s not a knock on the physicians and hospitals. It’s that the health care system isn’t providing support for rural patients. How do we better support them?

news@JAMA: What can be done to better support these clinicians and facilities?

Dr Joynt: If a patient with a heart attack shows up at a rural hospital, they may not have all the resources a larger hospital would have, but the resources are there to do a telemedicine consult with a specialist at a larger hospital or to transfer the patient when necessary. It just requires that we connect things a little better. The CAHs must have a system of triage. We need to be more creative about how we bring expertise to the rural hospitals. Right now there is not a whole lot of financial or systems incentives to make that happen.

I just don’t think we have been very patient-centered in the way we deal with medical centralization. We know that patients’ outcomes are better when they go to high-volume centers, but people are happier close to home. So maybe patients need to be transferred to get more complex care and then transferred closer to home as soon as possible for recovery. I would suspect it is about matching the right patient to the right hospital at the right time.

news@JAMA: Are there any examples of programs that are successfully doing this?

Dr Joynt: We have examples, such as telestroke programs. North Carolina is trying to create a statewide telehealth system, so no matter where the patient presents there is a system in place to get them to where they need to be. We have the ability to get creative about using technology to get the best medical technology to the patient in some of these areas.

Categories: Cardiovascular Disease/Myocardial Infarction, Health Policy, Pneumonia, Quality of Care