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The Quality of Some Rural Hospitals May Pose Greater Risk of Death

Update Date: Apr 04, 2013 03:30 PM EDT
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New evidence displayed the quality of hospitals in rural areas may be deteriorating, based on a study published in the Journal of the American Medical Association. In the past decade, while mortality rates at other hospitals have been decreasing, death rates of patients in rural critical access hospitals have been climbing.

Hospitals in small remote areas have been provided with special privileges from Congress for 15 years.  Medicare exempts these hospitals from financial pressure to operate efficiently and also exempts them from the requirement to reveal how their patients fare. These small critical access hospitals also receive more money from Medicare than most hospitals.  

"This carved-out group of hospitals seems to be falling further and further behind," said Dr. Karen Joynt of the Harvard School of Public Health, lead author of the study.

The research showed mortality rates at critical access hospitals for Medicare patients with heart attacks, heart failure and pneumonia were about the same at other hospitals in 2002. However, since then the figures from rural critical access hospitals and other hospitals have continued to grow apart.

In 2010, mortality rates at other hospitals reached 11.4 percent, dropping 0.2 percent each year since 2002. In contrast, critical access hospitals reached a mortality rate of 13.3 percent, raising the death rate by nearly 0.1 percent each year. Critical access hospitals also performed worse than other small, rural hospitals who did not receive special treatment from Congress and Medicare.

The hospitals' care may suffer because they don't have the latest sophisticated technology or specialists to treat the increasingly elderly and frail rural populations suggested Joynt and her co-authors, John Orav and Dr. Ashish Jha, also of Harvard. The researchers previously found that critical access hospitals were less likely to have intensive care units and lacked the ability to perform cardiac catheterizations, according to Kaiser Health News.

"As we have more advanced treatments, it's harder for rural hospitals to keep up," Joynt said. "It's hard to provide care for really, really sick patients in a resource-limited setting."

Hospital officials in these critical access facilities are not required to evaluate their performances for Medicare reports.  Joynt also suggested these hospitals could be victims of the government's failure to realize these facilities could need additional assistance in caring for patients.

"This is 1,000 hospitals, a quarter of the hospitals in the country, that are invisible," she said. "We've created a completely separate system, and in this case it looks like that has not done patients in these hospitals any favors."

"Mortality is just one small part of the picture of what qualities means," stated Brock Slabach, an executive at the National Rural Health Association (NRHA), in an effort to avoid overgeneralizations. He continued to state that NRHA research in fact found rural hospitals do better in patient satisfaction surveys when compared to urban hospitals.

The critical access program was launched by Congress in 1997 to avoid hospital closures that would then require patients to travel 35 miles to the nearest hospital in case of urgent emergency care. Hospitals with 25 or fewer beds qualified, as well as several hospitals near competitors in both rustic and urban areas who found a loophole to get into the program.

In 2011, 1,331 hospitals qualified for the program, which reimburses hospitals for all care costs of Medicare patients, plus an extra 1 percent. Other hospitals do not always receive the full cost of coverage since set sums are given to patient's based on their illnesses. Overall Medicare spends approximately $8 billion a year providing for these critical access hospitals, which merely accounts for five percent of the United States' inpatient and outpatient expenses, according to Congress' Medicare Payment Advisory Commission.

Kansas, Iowa, Minnesota, Texas and Nebraska have the most critical access hospitals, each having between 65 and 83 facilities. By 2011, the only states and provinces to lack critical access programs were Connecticut, Delaware, the District of Columbia, Maryland, New Jersey, Rhode Island, Puerto Rico and the Virgin Islands.

Joynt and her colleagues determined that although some critical access hospitals had improved since previous studies, overall the group had done worse when compared with others.

One medical professor at Stanford, Dr. John Ioannidis, applauded the paper as "the best study to date" on the issue and questioned whether policymakers should enact changes on hospitals in the program.

"Trying to impose quality data collection and reporting in such hospitals that have already strained resources may actually do more harm than good," Ioannidis wrote. "Even for non-CAHs, the evidence is tenuous that performance and quality initiatives do work."

Joynt suggested telemedicine could help these rural hospitals confronting complex cases by receiving advice from specialists elsewhere.

"I see this as more of a systems problem than just a hospital problem," Joynt said. "I don't think that there really exists the right sort of systems or incentives to make that happen."

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