In a study published in the July 6 issue of JAMA, it was revealed that critical access hospitals (CAHs) had poor clinical capabilities, sub-standard processes of care and a higher mortality rate due to conditions such as heart attack, congestive heart failure or pneumonia, compared to non-CAHs. In this study data was collected from 4,500 CAHs, each of which has no more than 25 emergency beds available and are located at a distance of more than 35 miles from the nearest hospital.

This publication informs that CAHs are of vital importance in the U.S. health care system, delivering medical care to rural people who may not have immediate access to a larger inpatient facility. CAHs were developed for providing immediate inpatient and emergency services to approximately 20% of the US population living in rural areas. CAHs are supported under broad policy interest, but still little is known about the quality of care they provide.

A study was conducted at the Harvard School of Public Health, Boston, by Karen E. Joynt, M.D., M.P.H and colleagues, for evaluating the clinical and personnel resources, quality of care provided and patient outcomes of CAHs.

This study included data from Medicare fee-for-service beneficiaries from 4,738 hospitals. During the enrollment period (2008-2009), patients were included 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).

This study has demonstrated that the infrastructure available at CAHs is far less than other hospitals. In this research study, CAHs compared to other hospitals had intensive care units (380 [30%] and 2,581 [74.4%]), cardiac catheterization capabilities (6 [0.5%] and 1,654 [47.7%], basic electronic health records (80 [6.5%] and 445 [13.9%]), respectively.

On the basis of Hospital Quality Alliance process measures, the care provided to AMI patients was compliant 91.0% of the time for CAHs and 97.8% for non-CAHs.

Commensurate with severity of the condition the difference in compliance was larger for CHF (80.6 percent vs. 93.5 percent) and smaller but still significant for pneumonia (89.3 percent vs. 93.7 percent).

The 30-day risk-adjusted mortality rate was high for CAHs, for the three conditions mentioned above compared to non-CAHs.

There was a significant difference in absolute 30-day mortality rates for patients admitted in CAHs than non-CAHs. Mortality rate was seen to be 7.3% higher for AMI patients (23.5% vs. 16.2 %) 2.5% higher for CHF (13.4 % vs. 10.9%) and 2% higher for pneumonia (14.1% vs. 12.1%).

The researchers claim that the CAHs are technologically less advanced and lack the necessary resources to provide quality medical care, consistent with the standard quality metrics. Patient outcomes at CAHs are worse compared to non-CAHs, despite a decade of support through concerted policy efforts to improve rural health care. The authors suggest that this is a wakeup call for us to genuinely support up-gradation of infrastructure at CAHs for providing quality inpatient care to one and all in the US.

Editorial: Critical Access Hospitals and the Challenges to Quality Care

The findings of this study should serve as a stimulus to explore strategies on how to improve quality and outcomes for those patients receiving care at a CAH, according to Martin S. Lipsky, M.D., and Michael Glasser, Ph.D., of the University of Illinois College of Medicine at Rockford, in an accompanying editorial.

“The national translational research agenda should include research that focuses on how to adapt best practices to rural settings. Academic health partnerships that prepare health professionals for careers in rural settings and explore how to collaborate with rural hospitals to use technological solutions such as telemedicine, e-ICUs, and e-consults may be helpful.”

“Although the differences in CAH outcomes may be accounted for by cultural, economic, and other environmental issues, this study should also serve as a challenge to improve the health care experienced by rural residents. All residents in the United States should have access to safe, high-quality health care and should have confidence in the health care system regardless of where they live.”

JAMA. 2011;306[1]96-97.

Written by Anne Hudsmith