Critical Access Hospitals Perform Well on Common Surgeries

Troy Brown, RN

May 18, 2016

Patients who undergo common surgical procedures at small, rural (critical access) hospitals have similar 30-day mortality rates, lower serious complication rates, and lower Medicare expenditures compared with those who undergo the procedures at non-critical access hospitals, a new study shows.

"[T]hese findings contrast previously published literature about nonsurgical admissions in these same settings and inform legislators about the valuable role critical access hospitals provide in the US health care system," the researchers write.

Andrew M. Ibrahim, MD, from The Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, and colleagues report their findings in an article published in the May 17 issue of JAMA.

"Critical access hospital designation was created to help ensure access to the more than 59 million people living in rural populations," the authors explain. "Established in 1997 under the Medicare Rural Hospital Flexibility Program when policy makers were worried these hospitals would close due to financial hardship, the critical access hospital provision entitled hospitals to increased reimbursements if they had fewer than 25 inpatient beds and were located more than 35 miles away from another hospital."

The researchers analyzed data from the Medicare Provider Analysis and Review file between 2009 and 2013 to determine outcomes and costs among Medicare beneficiaries who underwent one of four common surgical procedures at critical access (n = 828) and non-critical access (n = 3676) hospitals.

The surgical procedures were 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), and hernia repair (4291 for critical access and 300,410 for non-critical access).

Study outcomes included rates of mortality, overall complications, serious complications, reoperations, and readmissions. The investigators adjusted for potential confounders including age, sex, race, and comorbidities; admission type (elective, urgent, emergency); and type of surgery.

Thirty-day mortality rates did not differ significantly between critical access and non-critical access hospitals (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89 - 1.03; P = .28). In-hospital mortality rates were lower in critical access than non-critical access hospitals (2.9% vs 3.9%; OR, 0.69; 95% CI, 0.62 - 0.77; P < .001).

Moreover, rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.32 - 0.39; P < .001) and overall complications (17.5% vs 25.4%; OR, 0.55; 95% CI, 0.52 - 0.58; P < .001) were significantly lower in critical access compared with non-critical access hospitals.

In contrast, rates of readmission within 30 days were higher in critical access than non-critical access hospitals (14.7% vs 13.3%; OR, 1.13; 95% CI, 1.08-1.18; P < .001).

Patients who underwent surgery at critical access hospitals were less likely to have comorbid conditions than those at non-critical access hospitals, with lower rates of heart failure, diabetes, obesity, or multiple comorbidities (percentage of patients with two or more comorbidities; 60.4% vs 70.2%; P < .001).

The proportion of patients who were transferred to another acute care hospital was higher in critical access hospitals than in non-critical access hospitals (4.7% vs 0.8%; P < .001).

"These findings are consistent with the dual role rural surgeons perform in providing safe local care on appropriately selected patients but also in triaging higher-risk patients to larger centers before an operation. For medical conditions, which are less elective than the surgical procedures that we studied, it is often not possible to make decisions before hospitalization occurs," the researchers write.

Medicare expenditures were also lower at critical access compared with non-critical access hospitals ($14,450 vs $15,845; difference, −$1395; P < .001).

"This study may have important policy implications for payers and policy makers responding to mandates in the Affordable Care Act to evaluate health care services for rural Americans," the authors note. Critical access hospitals may find it beneficial to participate in certain reforms such as bundled payment programs and Medicare accountable care organizations.

The authors have disclosed no relevant financial relationships.

JAMA. 2016;315:2095-2103. Abstract

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