Care in Rural Critical Access Hospitals

Despite policy efforts to help critical access hospitals, many of them simply don't have the resources to ensure high-quality care.

Although 20% of Americans still live in rural communities and rely on critical access hospitals (CAH) for their care. A new study published in the Journal of the American Medical Association determined that CAHs face great challenges in delivering high-quality care despite broad policy interest in helping them.

More than a quarter of acute care hospitals have CAH designation. The purpose of CAHs is to provide care to individuals who live in rural areas. Typically, CAHs have no more than 25 acute care beds and are more than 35 miles from the nearest hospital. And hospitals designated a CAH are eligible for cost-based reimbursement, which improves the financial stability of these hospitals.

In general, CAHs were located in areas with a lower median income than non-CAHs and patients tended to be older. The report focused on the quality of care for three conditions: congestive heart failure, acute myocardial infarction and pneumonia.

For all three conditions CAHs had lower performances than non-CAHs and patients at CAHs had a higher 30-day risk-adjusted mortality rate. The problem with CAHs is that they have “fewer clinical and technological resources.” CAHs were less likely to have intensive care units, cardiac catheterization capability or the ability to perform surgeries. They typically had fewer specialists. And patients admitted to CAHs were more likely to be transferred to another acute care hospital. For cases of acute myocardial infarction, almost 30% of CAH patients are transferred compared to only 9.5% of acute myocardial infarction patients at non-CAHs.

The report suggests more efforts to bring needed practitioners to these under-served areas — half of CAHs are located in the Midwest. Partnerships with health care systems would make clinicians with specialty training available to CAHs on a rotating schedule.

While the CAH designation means hospitals that may have been on the brink of closing are financially stable enough to continue operating, these institutions “perform worse on process measures and have higher mortality rates than non-CAHs.”

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