"Critical access" hospitals show higher patient mortality and worse performance on standard measures of health care quality, compared with other hospitals, according to a July 6 report in JAMA.

Critical access hospitals are so designated because they provide close-to-home basic inpatient and emergency care for people who otherwise would have no such access – chiefly the 20% of Americans who live in rural areas. The designation was created in 1997 by the federal government to provide extra reimbursement for small, geographically isolated hospitals that were struggling with financial insolvency, and it has succeeded in allowing them to remain open. At present, more than one-fourth of the acute-care hospitals in the United States are critical access hospitals.

However, little is known about the quality of care provided at these facilities, largely because they are exempt from reporting to the Joint Commission performance measure program and the Hospital Quality Alliance national public reporting program, said Dr. Karen E. Joynt of the department of health policy and management, Harvard School of Public Health, Boston, and her associates.

"We sought to examine critical access hospitals’ clinical and personnel resources, the quality of care they deliver, and their patients’ outcomes. We focused on three common conditions – congestive heart failure, acute myocardial infarction, and pneumonia," the researchers said.

To do so, they assessed Medicare data on acute care services and data from the American Hospital Association on hospital characteristics, and linked this with county-level data on household incomes and the poverty rate in all 50 states. They identified 2,351,701 index admissions to 4,738 hospitals nationwide for these three conditions during a recent 1-year period, including 149,989 admissions to 1,268 critical access hospitals (JAMA 2011;306: 45-52).

For all three conditions, patients admitted to critical access hospitals had higher risk-adjusted 30-day mortality than did those admitted to other hospitals. Thirty-day mortality was 7.3% higher for patients with acute MI (23.5% vs. 16.2%), 2.5% higher for patients with CHF (13.4% vs 10.9%), and 2% higher for patients with pneumonia (14.1% vs 12.1%).

Similarly, for all three conditions, critical access hospitals had poorer performances on measures of health care quality. For 14 of the 17 individual measures, critical access hospitals were consistently outperformed by other hospitals even after the data were adjusted to account for differences in case mix and hospital characteristics.

"These findings suggest that efforts to date have been insufficient in improving the quality of inpatient care in rural communities – and indicate a need for greater policy attention to the challenges [critical access] hospitals face," Dr. Joynt and her colleagues said.

"More than a decade after major federal and state efforts to save U.S. rural hospitals, these findings should be seen as a call to focus on helping these hospitals improve the quality of care they provide so that all individuals in the United States have access to high-quality inpatient care regardless of where they live," they added.

Differences in personnel and technical capabilities explain some of the discrepancy in patient mortality between critical access hospitals and other hospitals. For example, in this study, critical access hospitals were located in counties that had sevenfold fewer cardiologists and pulmonologists per 100,000 population, compared with other hospitals.

Rural hospitals are known to have difficulty in recruiting clinicians, particularly specialists. Strategies that may address this problem include promoting partnerships with large health care systems, allowing on-site rotations by specialists, increasing the use of telemedicine, and establishing formal referral and transfer agreements that allow patients to stay close to home while still facilitating access to specialty care.

"The use of technology, particularly telemedicine and clinical data exchange, has important applications in underserved areas. [But currently,] critical access hospitals lack financial capital and access to the personnel needed to install and effectively maintain these systems," the researchers said.

One of Dr. Joynt’s associates reported ties to UpToDate and Humedica. No other financial conflicts of interest were disclosed.

A Challenge to Improve Rural Health Care

"The report by Joynt et al. is likely to be disappointing to those committed to rural health care," Dr. Martin S. Lipsky and Michael Glasser, Ph.D., wrote in an editorial (JAMA 2011;306:96-7).

"Although the differences in critical access hospitals’ outcomes may be accounted for by cultural, economic, and other environmental issues, this study should also serve as a challenge to improve the health care experienced by rural residents.

"All residents of the United States should have access to safe, high-quality health care and should have confidence in the health care system regardless of where they live," Dr. Lipsky and Dr. Glasser said.

Dr. Lipsky and Dr. Glasser are in the department of community and family medicine at the University of Illinois, Rockford. Dr. Glasser is also at the National Center for Rural Health Professions, Rockford. Dr. Lipsky was formerly on the board of the Midwest Medical Center, Galena, Ill. Dr. Glasser reported ties to the Illinois Critical Access Hospital Network.

'Critical Access' Hospitals Show Higher Patient Mortality