title: Effect of critical access hospital conversion on patient safety.
abstract: BACKGROUND
  The Medicare Rural Hospital Flexibility Program of the 1997 Balanced Budget Act allowed hospitals meeting certain criteria to convert to critical access hospitals (CAH) and changed their Medicare reimbursement mechanism from prospective payment system (PPS) to cost-based.
  
  
  OBJECTIVE
  To examine the impact of CAH conversion on hospital patient safety.
  
  
  METHODS
  Secondary data on hospital patient safety indicators (PSIs), hospital CAH status, patient case-mix, and market variables, for 89 Iowa rural hospitals during 1997-2004.
  
  
  METHODS
  We employed quasi-experimental designs that use both control groups and pretests. The hospital-year was the unit of analysis. We used generalized estimating equations logit and random-effects Tobit models to assess the effects of CAH conversion on hospital patient safety. The models were adjusted for patient case-mix and market variables. Sensitivity analyses, which varied by sample and statistical model, were used to examine the robustness of our findings.
  
  
  METHODS
  PSIs were computed from Iowa State Inpatient Databases (SIDs) using Agency for Healthcare Research and Quality indicators software. Hospital CAH status was extracted from Iowa Hospital Association. Patient case-mix variables were extracted from Iowa SIDs. Market variables came from Area Resource File (ARF).
  
  
  RESULTS
  CAH conversion in Iowa rural hospitals was associated with better performance of risk-adjusted rates of iatrogenic pneumothorax, selected infections due to medical care, accidental puncture or laceration, and composite score of four PSIs, but had no significant impact on the observed rates of death in low-mortality diagnosis-related groups (DRGs), foreign body left during procedure, risk-adjusted rate of decubitus ulcer, or composite score of six PSIs. Conclusion. CAH conversion is associated with enhanced performance of certain PSIs.
authors.affiliation: Division of General Internal Medicine, University of Pennsylvania, 1215 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA.
authors.forename: Pengxiang
authors.initials: P
authors.lastname: Li
authors.forename: John E
authors.initials: JE
authors.lastname: Schneider
authors.forename: Marcia M
authors.initials: MM
authors.lastname: Ward
mesh_terms: D003430:Cross-Sectional Studies; D006297:Health Services Accessibility; D006302:Health Services Research / Q000379:methods; D017721:Hospital Costs; D006780:Hospitals, Rural / Q000191:economics* / Q000592:standards*; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology; D007484:Iowa / Q000453:epidemiology; D019300:Medical Errors / Q000706:statistics & numerical data; D016344:Medicare Part A; D015233:Models, Statistical; D011445:Prospective Payment System; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D012051:Reimbursement Mechanisms / Q000639:trends*; D020379:Risk Adjustment; D012307:Risk Factors; D017751:Safety Management / Q000706:statistics & numerical data*; D013997:Time Factors; D014481:United States