Critical issue: Mortality rates worsen at small, rural hospitals

Researchers call for new policies to improve quality at critical-access facilities

new study in JAMA finds that mortality rates at critical-access hospitals (CAHs) have increased during the last decade as the facilities struggled with tightening budgets and aging patient populations.

Background on the critical-access hospital program

According to Harvard School of Public Health's Karen Joynt and colleagues, the CAH program was launched in 1997 as part of an effort to halt a wave of hospital closures in rural communities. Hospitals with 25 beds or less that were located at least 35 miles from the next closest inpatient facility qualified as CAHs.

Under the program, CAHs qualify for reimbursements of 101% of costs with exemption from prospective payments.

CAHs also are excused from participation in national quality improvement initiatives in an effort to ease the burden on administrators and physicians at CAHs. However, experts in recent years have questioned the exemption policy's impact on quality at the facilities, Reuters reports.

  • Trends in critical access hospitals: Six CAH administrators detail the struggles facing the small, rural facilities.

Study finds increase in mortality rates

For the JAMA study, Joynt and colleagues examined risk-adjusted, 30-day mortality rates for Medicare patients suffer a heart attack, heat failure, or pneumonia from 2002 to 2010 at CAHs and non-CAHs.

They found that mortality rates at CAHs rose an average of 0.1% per year over the nine-year study period. In comparison, mortality rates at non-CAHs dropped an average of 0.2% per year.

By 2010, the overall mortality rate for the three conditions at CAHs was 13.3%, compared with 11.4% at other acute-care hospitals.

Researchers call for new policies to improve quality at CAHs

"Given the substantial challenges that [CAHs] face, new policy initiatives may be needed to help these hospitals provide care for U.S. residents living in rural areas," the researchers wrote in JAMA.

They note that the way CAHs are paid and their exclusion from quality reporting programs may reduce incentives to improve care. "This is 1,000 hospitals, a quarter of the hospitals in the country, that are invisible," Joynt says, adding, "We've created a completely separate system, and in this case it looks like that has not done patients in these hospitals any favors."

In addition, the researchers say that CAHs may struggle to adopt advanced technology systems. "New interventions, such as close partnerships with larger institutions, use of technologies such as teleconsultation, or programs that help clinicians at (critical-access hospitals) determine which patients may need a higher level of care, may provide benefit for patients at these hospitals," the researchers write (McKinney, Modern Healthcare, 4/2 [subscription required]; Pittman, Reuters, 4/2; Gever, MedPage Today, 4/2; Rau, Kaiser Health News/USA Today, 4/2).

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