Date Published: 5 July 2011

Care at Critical Access Hospitals in rural areas of USA

Patients at small, isolated, rural hospitals in United States more likely to receive lower quality of care compared with other hospitals according to a recent study by researchers at Harvard University, USA.

The United States government defines critical access hospitals as geographically isolated facilities with no more than 25 acute care beds. More than a quarter of acute care hospitals in the United States have been designated critical access hospitals by the Medicare Rural Hospital Flexibility Program of the 1997 Balanced Budget Act. The program created payment reform that has kept small rural hospitals financially solvent, preserving access to care for rural Americans who might otherwise have no accessible inpatient provider.

In the first United States national study to examine care at critical access hospitals in rural areas of the U.S., Harvard School of Public Health researchers found that critical access hospitals have fewer clinical capabilities, lower quality of care, and worse patient outcomes compared with other hospitals. The researchers found that patients admitted to a critical access hospital for heart attack, congestive heart failure, or pneumonia were at greater risk of dying within 30 days than those at other hospitals. The study shows that despite more than a decade of policy efforts to improve rural health care, substantial challenges remain.

" Critical access hospitals face a unique set of obstacles to providing high quality care, and our findings suggest that their needs are not being met by current health policy efforts," said Karen Joynt, a research fellow in HSPH's Department of Health Policy and Management and the lead author of the paper.

Joynt and her colleagues analyzed the records of 2,351,701 Medicare fee-for-service patients at 4,738 hospitals (26.8% of which were critical access hospitals) diagnosed with acute myocardial infarction (heart attack), congestive heart failure, and pneumonia in 2008-2009. Compared with other hospitals, critical access hospitals were less likely to have intensive care facilities, advanced cardiac care capabilities, or even basic electronic health records. These hospitals were less likely to provide appropriate evidence-based care, as measured by the Hospital Quality Alliance metrics.

Patients admitted to critical access hospitals had 30% to 70% higher odds of dying within 30 days after being admitted for heart attacks, congestive heart failure or pneumonia.

" We were surprised at the magnitude of these findings," said Ashish Jha, senior author on the study and an associate professor in HSPH's Department of Health Policy and Management. " These findings suggest that we need to redouble our efforts to help these hospitals improve."

" To improve the quality of care patients receive at critical access hospitals, policy makers could explore partnerships with larger hospitals, increasing use of telemedicine, or inclusion of these hospitals in national quality improvement efforts," said Joynt. "Helping these hospitals improve is essential to ensuring that all Americans receive high-quality care, regardless of where they live."

Study authors included Yael Harris, director of the Office of Health IT & Quality at the Department of Health and Human Services and E. John Orav, associate professor in the Department of Biostatistics at HSPH.

Reference to Paper:
"Quality of Care and Patient Outcomes in Critical Access Rural Hospitals," Karen E. Joynt, Yael Harris, E. John Orav, Ashish K. Jha, Journal of the American Medical Association, July 6, 2011.

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