JAMA: CAHs come up short on care processes

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Critical access hospitals (CAHs) face a litany of challenges including fewer clinical capabilities and lower care process performance compared with non-CAH facilities, according to research published July 6 in the Journal of the American Medical Association.

In the study, Karen E. Joynt, MD, MPH, from the Department of Health Policy and Management at the Harvard School of Public Health, and colleagues measured clinical capabilities, performance on processes of care and 30-day mortality rates in a retrospective analysis in 4,738 U.S. hospitals of Medicare fee-for-service beneficiaries with myocardial infarction (MI), congestive heart failure (CHF) and pneumonia who were discharged in 2008-2009.

“CAHs play a crucial role in the U.S. rural safety net,” the authors wrote. “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 U.S.; however, little is known about the quality of care they provide or the outcomes their patients achieve.”

Compared with 3,470 non-CAH facilities, the researchers found that the 1,268 CAHs were less likely to have intensive care units (380 versus 2,581), cardiac catheterization capabilities (six versus 1,654) and basic EHRs (80 versus 445) than their non-CAH counterparts.

“The CAHs had lower performance on processes of care than non-CAHs for all three conditions examined,” noted Joynt and colleagues. For MI, the researchers found the performance on processes at 91 percent in CAHs versus 97.8 percent in non-CAHs; 80.6 percent in CAHs versus 93.5 percent in non-CAHs for CHF; and 89.3 percent in CAHs versus 93.7 percent in non-CAHs for pneumonia.

“Patients admitted to CAHs had higher 30-day mortality rates for each condition than those admitted to non-CAHs,” the authors added. For MI, the rates were 23.5 percent in CAHs versus 16.2 percent in non-CAHs; 13.4 percent in CAHs versus 10.9 percent in non-CAHs for CHF; and 14.1 percent in CAHs versus 12.1 percent in non-CAHs for pneumonia.

The researchers noted limitations in using administrative data as they “fail to capture important clinical and patient characteristics [such as educational attainment] that likely affect outcomes. Based on our sensitivity analysis, however, it is unlikely that any unmeasured confounder could be strong enough to fully account for the difference between CAH and non-CAH outcomes.” In addition, the authors noted that they lacked data on the experience or qualifications of the clinicians caring for patients at CAHs.

Joynt et al concluded that while CAHs play an essential role in ensuring access to healthcare for individuals, these institutions face many challenges; remain under-resourced in terms of both clinical and technological capabilities; perform worse on process measures and have higher mortality rates than non-CAHs. “More than a decade after major federal and state efforts to save U.S. rural hospitals, these findings should be seen as a call to focus on helping these hospitals improve the quality of care they provide so that all individuals in the United States have access to high-quality inpatient care regardless of where they live.”