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Small, rural hospitals lag on some quality measures

By Genevra Pittman

NEW YORK (Reuters Health) - Although fewer people are dying shortly after treatment for heart attacks, heart failure and pneumonia at most U.S. hospitals than a decade ago, the same trend doesn't apply to certain small, rural facilities, a new study suggests.

So-called critical access hospitals - which have no more than 25 beds and are typically miles from the nearest other hospital - are exempt from reporting those sort of quality and outcomes data to the government.

That decision was meant to make life easier for already stretched administrators and doctors at those hospitals, according to the lead author of the new study, Dr. Karen Joynt from Brigham and Women's Hospital in Boston.

But the exemption policy has been challenged in recent years by some who question its effect on quality and the incentive to improve.

In their analysis, Joynt and her colleagues found deaths during the month after a hospitalization for heart attack, heart failure or pneumonia dropped from 13 percent in 2002 to 11.4 percent in 2010 at non-critical access hospitals. But those rates held relatively steady at 12.8 to 13.3 percent at the small, rural facilities.

"There has been so much effort put into improving outcomes particularly for these three conditions that we've seen a pretty amazing drop in mortality at these non-critical access hospitals," Joynt told Reuters Health.

That's likely due to advances in technology and treatment, she added.

"It appears that critical access hospitals have just not been able to enjoy those same improvements. I think it's a system failure more than it is an individual hospital failure," Joynt said.

"As medicine has changed so much in the past decade… rural populations have sort of been left behind."

Critical access hospitals - which account for about one-quarter of U.S. hospitals - tend to see patients who are sicker or more disadvantaged than the average large facility, researchers said, which could also contribute to their slightly worse outcomes.

The new findings are based on an analysis of more than 10.2 million hospital stays among Medicare patients and are published in the Journal of the American Medical Association.

FAIR STANDARDS?

A representative from the American Hospital Association said the findings may not give an accurate representation of quality at small hospitals.

For example, small hospitals may selectively transfer some patients that could benefit from aggressive care to nearby hospitals.

"One reason for seeing a rise in mortality in some (critical access hospitals) could be because the hospital may tend to keep patients that are too sick for transfer or not stable enough," the representative told Reuters Health in an email.

Quality measures including one-month death and readmission rates are used by government programs to help determine the amount of funding going to non-critical access hospitals.

Although it might not seem fair to judge small, rural hospitals by the same standards, those facilities could likely benefit from collecting and tracking quality data, according to Joynt.

"You can't improve what you don't measure," she explained.

Pengxiang Alex Li, who has studied critical access hospitals at the University of Pennsylvania in Philadelphia, agreed.

"Having the hospitals do (quality) reports may actually help them," Li, who wasn't involved in the new study, told Reuters Health.

He said there are certain areas in which small, resource-limited hospitals might be expected to do just as well as large ones, such as in the proportion of patients they treat with recommended medications.

Along with reporting certain quality data, Li suggested critical access hospitals partner with larger facilities for resource-sharing and transfer of very sick patients.

Policy incentives could also help doctors at rural hospitals use teleconferencing to consult with far-away specialists, Joynt suggested.

"It seems like we ought to be able to do better in this day and age to support these hospitals," she said.

SOURCE: http://bit.ly/JjFzqx Journal of the American Medical Association, online April 2, 2013.

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