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A Heated Argument About the Quality of Care in Rural Hospitals

Map of hospitals designated "Critical Access Hospitals" that are eligible for Medicare financing to shore up health care access in underserved communities. (Source: the Flex Monitoring Team, a consortium of university health care research centers) Click to enlarge.

By Robin Pam

It’s not every day that the American Hospital Association calls out researchers for doing a “disservice” to a group of hospitals. Yet that’s just what the president, Rich Umbdenstock, said in response to a recent study in the Journal of the American Medical Association about the quality of care at Critical Access Hospitals, almost all of which are small, rural hospitals that serve as a first point of access to emergency care for the 20 percent of Americans who live in rural areas. 

He’s not the only one. The article has been generating heated responses among rural health experts from all corners in the weeks since its publication. 

For their paper, “Quality of Care and Patient Outcomes in Critical Access Hospitals,” researchers at the Harvard School of Public Health compared nationally recognized quality metrics on outcomes, processes, and facilities at Critical Access Hospitals with those at a group of non-Critical Access Hospitals. The results were not favorable to CAHs. The researchers’ analysis showed that compared with non-CAHs, CAHs had fewer clinical capabilities, worse measured processes of care, and higher mortality rates for patients with acute myocardial infarction (heart attack), congestive heart failure, and pneumonia.

The researchers concluded: “Despite more than a decade of concerted policy efforts to improve rural health care, our findings suggest that substantial challenges remain.” 

The critical access designation was created in 1997 to help small rural hospitals stay afloat financially. CAHs serve an important role in providing access to care for rural Americans. Most patients receive basic inpatient care at a CAH, and are then transferred to a larger tertiary care facility should they need more complex care than the hospital is capable of providing.

Prior to the designation, many small rural hospitals regularly closed because the economics of caring for the rural population did not work in their favor. The Medicare Rural Hospital Flexibility Program of 1997 changed that. The bill allowed small rural hospitals located more than 35 miles from the nearest hospital and with no more than 25 beds to be designated as critical access. The designation makes a hospital eligible for special financing from Medicare that has dramatically decreased hospital closures. Today, almost a quarter of the nation’s hospitals are critical access. Here’s a map of their locations:

“Understanding whether the CAH designation has been helpful, in not only improving access, but also in ensuring high-quality care, is a key element in evaluating federal efforts to ensure an effective rural health system,” the Harvard authors write.

Some Critical Access Hospitals and their defenders are taking issue with the study, questioning the relevance of the quality measures the researchers used. One critical access hospital CEO wrote on his blog that “quality in critical access hospitals needs to be measured differently than quality in urban hospitals.”

The American Hospital Association and National Rural Health Association both fired back in statements. “The report is simply deficient when it comes to understanding the basic role of a Critical Access Hospital within a rural community,” said Alan Morgan, NRHA CEO on the organization’s blog.  “The current quality measurement systems available do not adequately reflect the core work of what rural hospitals do on a daily basis.”

The Flex Monitoring Team, made up of researchers from the Universities of Minnesota, North Carolina, and Southern Maine, says the study authors overlooked several years of research they have conducted on quality at critical access hospitals. The team’s most recent trend analysis shows that quality at CAHs is improving. Scores on quality for each of the pneumonia measures they review increased 9 to 22 percent from 2005 to 2009.

Another complaint is that comparing critical access hospitals to non-critical access hospitals is difficult, since nearly all small rural hospitals have converted to critical access status. Robert Bowman, MD, a professor at AT Still University in Arizona, put it this way: “The article in JAMA prominently notes that critical access hospitals, those that are found in rural communities, have fewer resources. Any reader can understand that this could be a problem with regard to health care delivery.”  

Karen Joynt, MD MPH, the study’s lead author, agrees that critical access hospitals as a group have fewer resources and therefore face more challenges when providing basic care to vulnerable populations. In fact, she says, the intent of the study was to draw attention to these challenges. “This group of hospitals is really being asked to perform in a setting in which there are a lot of cards stacked against them,” said Joynt. The rural patient population is generally older, less likely to be insured, and more likely to have chronic health issues.

But ignoring rural hospitals’ performance on basic measures of quality by creating a separate set of metrics isn’t necessarily the answer, according to Joynt. “I have a hard time with the argument that rural patients shouldn’t get the same quality care as urban patients. It’s not fair.” 

CAHs do require different measures for some aspects of quality. For instance, the mortality measures used in the study do not entirely reflect quality of care at the hospitals, since many factors contribute to mortality outside of a hospital, especially in rural areas. Patients may arrive in a worse condition because of longer travel times; or CAHs may keep older and sicker patients who do not wish to be transferred to tertiary care facilities, driving up their mortality measures.

By contrast, CAHs’ poor performance on the process measures used in the study are more worrisome. Adherence to care protocols should be basic procedure at all hospitals, regardless of size, location, or sophistication of facilities. What’s more, these are fairly low-cost measures to track, says Joynt, and “you can’t improve your performance until you know what it is. I don’t get the feeling that CAHs have the resources to be tracking these things.”

“Our intent is to focus attention and resources to these hospitals, not to make it seem like these hospitals are doing a bad job. As a public health effort we need to do a better job of helping them,” said Joynt. She further says that the study’s results are not indicative of the performance of any one hospital. Instead, the results indicate that the systems are not in place to help critical access hospitals succeed at their mission. 

Increased focus on the delivery system under health care reform presents an opportunity to assess the future needs of this specific group of hospitals. Yet quality reporting to Hospital Compare, the primary collection of hospital quality data run by the Department of Health and Human Services, remains voluntary for critical access hospitals.

Rather than improving quality at rural hospitals, researchers and advocates have more often focused on increasing the supply of primary care physicians, nurse practitioners, and physicians assistants who choose to practice in rural communities. Provider supply is often seen as a proxy for quality, since rural areas tend to have many fewer providers per capita than other parts of the country.

The Harvard researchers instead suggest that there are other ways to focus on improving quality in rural hospitals that are even more basic than increasing the number of providers. Networks that facilitate communication and support among rural hospitals, the increasing adoption of telemedicine, and more participation in public data reporting for rural hospitals are all lower-cost ways to improve the quality of care in these critical locations.

Ultimately, says Joynt, “These are a group of hospitals and a group of patients that face a lot of challenges. It passes the sniff test to think that these hospitals have some challenges.” And everyone, Harvard researchers and their critics alike, is looking for the best way to help them address these challenges to better serve a vulnerable population.

Last modified Mon, 1 Aug, 2011 at 11:28