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09-04-2013 | Cardiology | Article

Rural critical access hospitals falling behind in performance


Free abstract

medwireNews: Medicare beneficiaries who receive inpatient care at critical access hospitals (CAHs) in rural communities have higher 30-day mortality rates for acute myocardial infarction, congestive heart failure, and pneumonia than patients who visit other acute care hospitals, a study finds.

"Our findings suggest that the supports contained in the CAH program have not been adequate to help these hospitals overcome the challenges imposed by caring for this vulnerable patient population in remote settings," observe Karen Joynt (Harvard School of Public Health, Boston, Massachusetts) and colleagues.

The retrospective observational study published in JAMA included data from Medicare fee-for-service patients admitted to US acute care hospitals for the treatment of acute myocardial infarction (1.9 million admissions), congestive heart failure (4.5 m admissions) and pneumonia (3.9 m admissions).

Of the 3968 hospitals included in 2002, 860 (22%) were classified as CAHs due to having no more than 25 beds and being located at least 35 miles from the nearest alternative source of inpatient care (with exceptions). By 2010, the proportion of CAHs increased to 1264 (28%) of 4519.

While CAH and non-CAH mortality rates were similar in 2002, between 2002 and 2010 they increased 0.1% per year in CAHs but decreased 0.2% in non-CAHs. This resulted in a significant annual difference in change of 0.3%, and meant that mortality rates were significantly higher in CAHs compared with non-CAHs by 2010 (13.3% vs 11.4%).

The authors also observed this disparity when they considered each condition individually as well as when they compared CAHs with other small, rural hospitals.

The authors say there could be several reasons for their findings. For example, CAHs are exempt from collecting and reporting performance data, which could lead to inadequate feedback to hospital management.

They also say that the cost-based reimbursement mechanism for CAHs may reduce incentives to push for efficiency.

They add that CAHs have failed to keep pace with new technologies and the changing nature of hospital care.

"However, even for conditions less dependent on advanced technologies, such as pneumonia or [congestive heart failure], mortality in CAHs worsened," they write.

The authors also suggest that a higher burden of social issues among the patient population may have hindered CAHs' performance over the years as they took on more patients who suffered from poverty and unemployment.

"Given the substantial challenges that CAHs face, new policy initiatives may be needed to help these hospitals provide care for US residents living in rural areas," the authors conclude.

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Peter Sergo, medwireNews Reporter

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