Quality of Care and Patient Outcomes in Critical Access Rural Hospitals

Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 07/2011; 306(1):45-52. DOI: 10.1001/jama.2011.902
Source: PubMed


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.
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.
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.
Clinical capabilities, performance on processes of care, and 30-day mortality rates, adjusted for age, sex, race, and medical comorbidities.
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).
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.

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    • "Given that CAHs often have many financial constraints, some low-volume, capital-and other resource-intensive services,.jacr.2015.09.008such as advanced imaging, may not be available on the premises of a CAH to meet the health care needs of their underserved populations[10]. Members of rural communities served by most CAHs are generally older, sicker, and poorer than their urban counterparts[7,11,12]. At the same time, those community members often need services that ordinarily would not be available at rural hospitals without the CAH designation. "
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    ABSTRACT: Purpose: Although all critical access hospitals (CAHs) provide basic medical and radiographic imaging services, it remains unclear how CAHs provide additional imaging services given relatively low patient volumes and high resource costs. The aim of this study was to examine whether CAHs with more resources or access to resources through affiliation with larger systems are more likely to offer other imaging services in their communities. Methods: Linking data from the American Hospital Association's annual hospital surveys and the American Hospital Directory's annual surveys from 2009 to 2011, multivariate logistic regressions were performed to estimate the likelihood of individual CAHs with greater financial resources or network affiliations providing specific imaging services (MRI, CT, ultrasound, mammography, and PET/CT), while adjusting for the number of beds, personnel, inpatient revenue share, case mix, rural status, year, and geographic location. Results: Hospital total expenditures were positively associated with the provision of MRI (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19), mammography (OR, 1.11; 95% CI, 1.01-1.16), and PET/CT (OR, 1.04; 95% CI, 1.01-1.06). Network affiliation was positively associated with the availability of MRI (OR, 1.75; 95% CI, 1.27-2.39), CT (OR, 2.17; 95% CI, 1.15-4.09), ultrasound (OR, 2.03; 95% CI, 1.17-3.52), and mammography (OR, 2.00; 95% CI, 1.47-2.71). Rural location was negatively associated with the availability of PET/CT (OR, 0.65; 95% CI, 0.49-0.88). Conclusions: Total hospital expenditures and network participation are important determinants of whether CAHs provide certain imaging services. Encouraging CAHs' participation in larger systems or networks may facilitate access to highly specialized services in rural and underserved areas.
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    • "The rural–urban difference is particularly pronounced in the case of medical specialties, where only 2.5% of specialists practice rurally (CIHI 2012). When compared to urban sites, rural sites in both Canada and the United States have been shown to have substantially poorer accessibility and outcomes with respect to interventions requiring specialist skills (Joynt 2011; Fleet 2013). These observations suggest that the disparity of health care accessibility between rural and urban Canadians may be more drastic in the case of specialist care (Lamarche et al. 2010). "
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    • "This study was conducted in a hospital in the smaller town of Kafr eldawar that is surrounded by rural areas, opposite other available studies that were conducted in the main urban large cities in Egypt (Cairo and Alexandria). Previous studies have suggested better heath care in urban than in rural populations [26], [27]. "
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    ABSTRACT: Aim: Catheter associated urinary tract infections (CAUTI) are the most common hospital-acquired infection in ICUs. The aim of this study was to estimate the effectiveness of an intervention program by implementing urinary catheter bundle elements to reduce the CAUTI frequency in an ICU. Methods: The intervention study was conducted over a period of 6 months. During a pre-intervention phase, the base line catheter associated CAUTI incidence rates were determined and compared with the incidence rates during the post-intervention phase. The compliance of health care staff with urinary catheter bundle elements was also measured. The implemented CAUTI prevention bundle consisted of hand hygiene, wearing personal protective equipment, use of disposable gloves, cleansing of urethral meatus prior to catheter insertion using sterile saline, assessment of catheter need, aseptic urine sampling technique, and correct draining bag positioning. Results: During the study period, 55 out of 77 patients were diagnosed with a CAUTI. The mean CAUTI incidence rate for the pre-intervention period was 90.12/1,000 catheter days and for the post intervention phase 65.69/1,000 catheter days. The CAUTIs rate was inversely proportional to insertion bundle elements and maintenance bundle elements compliance rate. This negative relationship was statistically significant only with maintenance bundle elements (p=0.042) (rs=–0.828). The compliance rate of the ICU nurses to the bundle elements was raised to 100% during the last 2 months of the post intervention phase. Conclusion: Increased compliance to recommended catheter associated urinary tract infections preventive practices reduced the incidence of CAUTI in an ICU unit. It is simple and effective and is recommended as a part of patient safety culture.
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