title: Quality of care and patient outcomes in critical access rural hospitals.
abstract: BACKGROUND
  Critical access hospitals (CAHs) play a crucial role in the US rural safety net. Current policy efforts have focused primarily on helping these small, isolated hospitals remain financially viable to ensure access for individuals living in rural areas in the United States; however, little is known about the quality of care they provide or the outcomes their patients achieve.
  
  
  OBJECTIVE
  To examine the quality of care and patient outcomes at CAHs and to understand why patterns of care might differ for CAHs vs non-CAHs.
  
  
  METHODS
  A retrospective analysis in 4738 US hospitals of Medicare fee-for-service beneficiaries with acute myocardial infarction (AMI) (10,703 for CAHs vs 469,695 for non-CAHs), congestive heart failure (CHF) (52,927 for CAHs vs 958,790 for non-CAHs), and pneumonia (86,359 for CAHs vs 773,227 for non-CAHs) who were discharged in 2008-2009.
  
  
  METHODS
  Clinical capabilities, performance on processes of care, and 30-day mortality rates, adjusted for age, sex, race, and medical comorbidities.
  
  
  RESULTS
  Compared with other hospitals (n = 3470), 1268 CAHs (26.8%) were less likely to have intensive care units (380 [30.0%] vs 2581 [74.4%], P < .001), cardiac catheterization capabilities (6 [0.5%] vs 1654 [47.7%], P < .001), and at least basic electronic health records (80 [6.5%] vs 445 [13.9%], P < .001). The CAHs had lower performance on processes of care than non-CAHs for all 3 conditions examined (concordance with Hospital Quality Alliance process measures for AMI, 91.0% [95% CI, 89.7%-92.3%] vs 97.8% [95% CI, 97.7%-97.9%]; for CHF, 80.6% [95% CI, 79.2%-82.0%] vs 93.5% [95% CI, 93.3%-93.7%]; and for pneumonia, 89.3% [95% CI, 88.6%-90.0%] vs 93.7% [95% CI, 93.6%-93.9%]; P < .001 for each). Patients admitted to CAHs had higher 30-day mortality rates for each condition than those admitted to non-CAHs (for AMI: 23.5% vs 16.2%; adjusted odds ratio [OR], 1.70; 95% confidence interval [CI], 1.61-1.80; P < .001; for CHF: 13.4% vs 10.9%; adjusted OR, 1.28; 95% CI, 1.23-1.32; P < .001; and for pneumonia: 14.1% vs 12.1%; adjusted OR, 1.20; 95% CI, 1.16-1.24; P < .001).
  
  
  CONCLUSIONS
  Compared with non-CAHs, CAHs had fewer clinical capabilities, worse measured processes of care, and higher mortality rates for patients with AMI, CHF, or pneumonia.
authors: Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA. kjoynt@partners.org
authors: Karen E
authors: KE
authors: Joynt
authors: Yael
authors: Y
authors: Harris
authors: E John
authors: EJ
authors: Orav
authors: Ashish K
authors: AK
authors: Jha
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006328:Cardiac Catheterization / Q000592:standards / Q000706:statistics & numerical data; D057286:Electronic Health Records / Q000706:statistics & numerical data; D018588:Fee-for-Service Plans; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006333:Heart Failure / Q000401:mortality*; D006780:Hospitals, Rural / Q000592:standards*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D006278:Medicare; D009203:Myocardial Infarction / Q000401:mortality*; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010351:Patient Discharge; D011014:Pneumonia / Q000401:mortality*; D011787:Quality of Health Care; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology