Despite more than a decade of concerted policy efforts to improve rural healthcare, our findings suggest that substantial challenges remain. While CAHs provide much needed access to care for many of the nation’s rural citizens, we found that these hospitals, with their fewer clinical and technological resources, less often provided care consistent with standard quality metrics and generally had worse outcomes than non-CAHs. The absolute differences in outcomes were even larger than those reported in the initial work on this topic by Keeler et al., who demonstrated an excess all-cause mortality of 1.4% in rural hospitals using data from the 1980s,22
and comparable to differences noted by the Medicare Payment Advisory Committee (MedPAC) using data from 2003.2
These findings suggest that efforts to date have been insufficient in improving the quality of inpatient care in rural communities – and indicate a need for greater policy attention to the challenges these providers face.
The CAH designation, created with the goal of preserving access to care for Americans living in rural areas, directed financial resources to vulnerable rural hospitals at a time when many were closing due to financial insolvency. A number of regulations intended to promote quality were included in the legislation, including a formal requirement for credentialing and a state-run evaluations of quality. In return, designation as a CAH provided hospitals with financial security through cost-based reimbursement, which led to a significant improvement in these hospitals’ financial stability and allowed them to remain open, preserving access9, 24, 25
while maintaining patient satisfaction scores equal to or greater than non-CAHs.5
However, our findings suggest that these efforts have been inadequate in ensuring high quality care.
CAHs had significantly poorer performance on process measures, which may be due to fewer resources to devote to quality improvement. Because CAHs are not required to report HQA data,7
the CAHs that reported (which ranged from 39% of CAHs for AMI to 71% of CAHs for pneumonia) probably represent a higher-performing subset of CAHs than those choosing not to, likely understating the true differences in care. Further, CAHs have typically been exempt from pay-for-performance programs in the past, and will likely be excluded from national value-based purchasing efforts at least in the near-term.26–28
Engaging in the process of collecting and reporting data is an important step towards developing an internal quality improvement strategy;29
indeed, the Institute of Medicine has recommended that all CAHs participate in the HQA program for this reason.30
We found that personnel and clinical resources explained some of the mortality differences between CAHs and other hospitals. Assuring adequate personnel and resources is challenging for CAHs9, 25
given their difficulties in recruiting health care providers.25
Shorter lengths of stay, poor care transitions, or inadequate outpatient and home-based care31–33
may also contribute to poorer outcomes. Policy efforts to bring needed providers to underserved areas to ensure that CAHs have key clinical resources may be helpful. Given prior evidence that being a member of a hospital system may be related to improved clinical outcomes,34, 35
promoting partnerships with healthcare systems might be a useful strategy to help CAHs. Such partnerships could include onsite rotations by clinicians with specialty training, increased use of telemedicine, or formal referral and transfer agreements; arrangements that allow patients to remain close to home while still facilitating access to specialty care are likely to be particularly well-received by patients. One approach might be to provide financial incentives for tertiary care hospitals to partner with CAHs, potentially tying incentives to the CAH’s performance on quality metrics.
Although we did not find that the presence of an EHR explained a significant amount of the difference in clinical outcomes between CAHs and non-CAHs, this area warrants extra attention. The use of technology, particularly telemedicine and clinical data exchange, has important applications in underserved areas.36–39
CAHs lack financial capital and access to the personnel needed to install and effectively maintain these systems.40, 41
The federal effort to promote EHR adoption among CAHs has focused on technical assistance by the Regional Extension Centers (RECs).42
However, some RECs have elected not to work with CAHs and others are charging fees that may be unaffordable for CAHs. Policy makers may need to consider additional strategies to avoid exacerbating an already emerging digital divide.18
Adding rurality to our models seemed to explain some of the mortality differences we saw, and when we compared small, rural CAHs to small, rural non-CAHs, the excess mortality at CAHs was smaller. Our findings suggest that a substantial proportion of the barriers faced by CAHs are due to their size and their rural location, even after accounting for other factors such as clinical resources and personnel. Rurality is likely associated with other unmeasured factors such as travel distances to primary care or hospital, that impact outcomes; better understanding what factors are closely correlated with rurality that help explain these gaps in outcomes would be helpful in formulating effective interventions to help CAHs.
Despite the significant policy attention directed towards these vulnerable hospitals, there has been little empirical work on quality of care in a national sample of CAHs. Lutfiyya and colleagues examined performance on HQA process measures in 2004, the first year for which these data were available, and found that that CAHs had lower performance than non-CAHs.43
More recent comparisons have shown mixed results; some have found that rural hospitals provide lower quality care,44, 45
while others have failed to find a difference,46
although the study that found no difference examined self-selected hospitals engaged in national quality improvement programs.46
Using 2003 data, MedPAC found that, compared to other rural hospitals, CAHs had higher risk-adjusted mortality rates for CHF, AMI, pneumonia, stroke, and gastrointestinal hemorrhage; our findings extend the MedPAC work by focusing on a contemporary sample and a comparison group of non-rural hospitals, and by assessing care across a wide range of metrics while accounting for hospital characteristics and resources.2
Our study has limitations. We used administrative data, which fail to capture important clinical and patient characteristics (such as educational attainment) that likely affect outcomes. Based on our sensitivity analysis, however, we believe it is unlikely that any unmeasured confounder could be strong enough to fully account for the difference between CAH and non-CAH outcomes. We lacked data on the experience or qualifications of the clinicians caring for patients at CAHs, which could have potentially explained some of our findings. We were also unable to assess the role of patient choice in patterns of care; patients may have declined transfer for more advanced care due to personal preference even if clinicians recommended that a transfer occur. We could not examine outpatient care, and thus were unable to assess to what extent these differences might affect our findings. Because we relied on Medicare fee-for-service data for outcomes, we could not assess whether the patterns observed are also true for Medicare Advantage patients or for younger patients. Finally, mortality may be a crude measure of hospital quality, and therefore, we attempted to incorporate both structural and process measures to paint a more comprehensive view of care at CAHs.