Mortality Rates for Medicare Beneficiaries Admitted to Critical Access and Non–Critical Access Hospitals, 2002-2010

Study Questions:

How have risk-adjusted patient outcomes for hospitalized patients changed over time at critical access hospitals (CAHs), which typically serve more rural communities, relative to other hospitals across the United States?


This is a retrospective observational study by Joynt and colleagues using data from Medicare beneficiaries hospitalized with acute myocardial infarction, congestive heart failure, and pneumonia. Risk-adjusted patient outcomes for the three conditions were trended over time at CAHs relative to changes in outcomes for the same conditions at non-CAHs.


Accounting for differences in patient, hospital, and community characteristics, CAHs had similar mortality rates to non-CAHs in 2002 (composite mortality across all three conditions, 12.8% vs. 13.0%; p = 0.25); however, between 2002 and 2010, mortality rates increased 0.1% per year in CAHs, but decreased 0.2% per year in non-CAHs. This led to an annual difference in change of 0.3% (95% confidence interval [CI], 0.2-0.3%; p < 0.001), indicating worsening outcomes in CAHs. By 2010, CAHs had higher mortality rates compared with non-CAHs (13.3% vs. 11.4%; difference, 1.8%; 95% CI, 1.4-2.2%; p < 0.001). Patterns were similar for all three conditions and when each individual condition was examined separately. Comparing CAHs with other small, rural hospitals, similar patterns also were found.


Joynt and colleagues concluded that among Medicare beneficiaries with acute myocardial infarction, congestive heart failure, or pneumonia, 30-day mortality rates for those admitted to CAHs, compared with those admitted to other acute care hospitals, increased from 2002 to 2010. New efforts may be needed to help CAHs improve.


This piece is especially relevant for policy-makers and health care systems. CAHs have grown tremendously over the last decade due to policy initiatives that have generally favored greater reimbursement and exemption from national quality efforts required of other hospitals. Although this has led to fewer closures of hospitals in rural areas and improved access for patients in these regions, CAHs appear to have fallen behind other hospitals in recent years. These important findings suggest that additional attention on quality efforts at these hospitals is needed. For cardiologists, this work is especially relevant given ongoing work on regionalization of specialized cardiovascular procedures, such as primary PCI, which can be challenging for hospitals in rural communities.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Myocardial Infarction, Pneumonia, Heart Failure, Health Services Needs and Demand, Hospitals, Rural, Medicare, Hospitalization, United States

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