Quality of Care and Patient Outcomes in Critical Access Rural Hospitals

Study Questions:

What is the quality of care provided by critical access hospitals (CAHs) and the outcomes their patients achieve?


This was a retrospective analysis in 4,738 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. The main outcome measures were 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 = 3,470), 1,268 CAHs (26.8%) were less likely to have intensive care units (380 [30.0%] vs. 2,581 [74.4%], p < 0.001), cardiac catheterization capabilities (6 [0.5%] vs. 1,654 [47.7%], p < 0.001), and at least basic electronic health records (80 [6.5%] vs. 445 [13.9%], p < 0.001). The CAHs had lower performance on processes of care than non-CAHs for all three conditions examined (concordance with Hospital Quality Alliance process measures for AMI, 91.0% [95% confidence interval (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 < 0.001 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% CI, 1.61-1.80; p < 0.001; for CHF: 13.4% vs. 10.9%; adjusted OR, 1.28; 95% CI, 1.23-1.32; p < 0.001; and for pneumonia: 14.1% vs. 12.1%; adjusted OR, 1.20; 95% CI, 1.16-1.24; p < 0.001).


The authors concluded that as 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.


This study reports that although CAHs provide much-needed access to care for many of the nation’s rural citizens, these hospitals with their fewer clinical and technological resources, provide care less consistent with standard quality metrics and generally had worse outcomes than non-CAHs. These findings should serve as a stimulus to help these hospitals improve the quality of care they provide so that all individuals in the United States have access to high-quality inpatient and outpatient care regardless of where they live. One strategy for improving quality would be to develop networks of CAHs for the purposes of sharing resources, education, experience, and promoting operational efficiencies.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Odds Ratio, Myocardial Infarction, Intensive Care Units, Pneumonia, Fee-for-Service Plans, Cardiac Catheterization, Comorbidity, Hospitals, Rural, Inpatients, Patient Discharge, Electronic Health Records, Quality Improvement, Quality of Health Care, Heart Failure, Confidence Intervals, Medicare, Health Care Surveys, United States

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