Association of Hospital Critical Access Status With Surgical Outcomes and Expenditures Among Medicare Beneficiaries

Abstract

IMPORTANCE Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures. OBJECTIVE To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional retrospective review of 1 631 904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151 867 for non-critical access; cholecystectomy, 10 556 for critical access and 573 435 for non-critical access; colectomy, 10 198 for critical access and 577 680 for non-critical access; hernia repair, 4291 for critical access and 300 410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation. EXPOSURES Undergoing surgical procedures at critical access vs non-critical access hospitals. MAIN OUTCOMES AND MEASURES Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay >75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization. RESULTS Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P < .0001), diabetes (20.2% vs 21.7%, P < .001), obesity (6.5% vs 10.6%, P < .001), or multiple comorbid diseases (% of patients with Ն2 comorbidities; 60.4% vs 70.2%, P < .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.

Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States

“…Literature on rural health care quality is scarce as rural hospitals are traditionally exempted or excluded from quality reporting. Studies examining rural Critical Access Hospital (CAH) quality show mixed results, with worse outcomes for acute illness such as pneumonia, heart failure, and acute myocardial infarction (AMI) and equivalent outcomes for semielective surgery . Structural barriers in rural health care delivery related to regionalization networks, limitations in resource availability, and variation in emergency practitioners’ training all make adherence with sepsis resuscitation guidelines challenging in the rural setting.…”

Worsening Rural-Urban Gap in Hospital Mortality

“…Previous studies, however, suggest mixed results regarding this possibility. 6,7 Due to limitations of claims data, these studies cannot address the nuanced calculation of hospital mortality in the context of the mortality rate of the local nonhospitalized population, or the unique challenges of risk-adjusting quality measurement in rural areas. 18,19 In addition, previous reports of lower rural and community hospital quality have not considered patient preferences, triage decision trees, or admission thresholds.…”

“…Furthermore, between 2002 and 2010 overall hospital mortality increased for Medicare patients admitted to critical access hospitals, whereas mortality rates for Medicare patients in noncritical access hospitals improved during this same time period. 6 In contrast, Ibrahim et al 7 showed that Medicare patients admitted to critical access hospitals for common surgical procedures had equivalent mortality to Medicare patients admitted to noncritical access hospitals.…”

Hospital Quality and Medicare Expenditures for Bariatric Surgery in the United States

“…Methods for price-standardization was performed based on original reports from the Medicare Payment Advisory Commission and techniques later described by the Dartmouth Institute 19,20 . The same approach has been used in multiple previous studies to compare payments in Medicare administrative claims among surgical cohorts 10,21 .…”