AHA: Critical Access Hospital Study 'Distorted'

A report in a major medical journal is ruffling feathers.

Although the authors comment that "CAHs provide much-needed access to care for many of the nation's rural citizens," the study has ruffled a few feathers, at the American Hospital Association, where in a statement, president and CEO Rich Umbdenstock called the study "distorted." The National Rural Health Association was no more favorably impressed and called the report and its findings "deficient."

In a retrospective analysis of 4,738 U.S. hospitals, researchers examined outcomes for Medicare fee-for-service beneficiaries with acute myocardial infarction, congestive heart failure, and pneumonia who were discharged in 2008-2009. It found that patients admitted to CAHs had higher 30-day mortality rates than those admitted to non-CAHs. It also found that compared with other hospitals, CAHs were less likely to have ICUs, cardiac catheterization capabilities, and at least basic EHRs.

According to Ashish Jha, MD, MPH, associate professor of health policy at the Harvard School of Public Health and the senior author on the paper, although CAHs have gotten a lot of attention in terms of funding, they haven't gotten adequate attention in measuring quality.

"Across almost every measure we looked at, the quality of care was not as good; their adherence to clinical guidelines was not as good; patient outcomes were much worse at these hospitals," he said in an interview. "I think the magnitude of the differences were really substantial, suggesting we have a lot of work to do to help these hospitals get better."

But Nancy Foster, vice president for quality and patient safety policy at the AHA, says there are several reasons why CAHs are different from their larger counterparts in urban areas.

"It's really understanding the context of the care in critical access hospitals," she said in an interview. "By definition they're not designed to provide some of those more intensive services."

"It's sort of like looking at a dachshund and saying, 'but it's not as tall as a German shepherd.' Of course; it's not supposed to be a German shepherd," she adds. "It's that 'fit-for-use' concept, and critical access hospitals have different purposes than large academic medical centers."

She contends that whether or not a CAH has ICU or cardiac catheterization capabilities is not a fair measure of its quality because those types of services are more often performed at larger hospitals after a patient has been stabilized and transferred. Indeed, according to the AHA's statement about the JAMA study, "the established protocol of CAHs is to transfer patients who may benefit from more aggressive treatment and who are clinically stable enough for transport to larger hospitals that provide some of the more advanced services cited in the report."

But there's also the issue of the poorer outcomes and higher mortality that the study identified. Although the AHA said in its statement that the JAMA study does not count in its performance information "patients who are transferred from the CAH to a larger hospital," Jha contends that's not the case.

"We did a whole series of analyses to try to understand what the impact of the transfer situation was," he says, adding that the paper acknowledges that CAHs transfer many of their patients. "So we did a series of what's called sensitivity analyses where we tried to look at what impact that had. What if you included the transfer patients; what impact would that have on our outcomes? What if you excluded the transfer patients? We looked in a variety of different ways to try to understand the transfer situation. And the bottom line was it didn't make a big difference in terms of the outcomes. Critical access hospitals still had worse outcomes, no matter how you treated the transfer patients in the analysis."

The University of Minnesota Rural Health Research Center/Flex Monitoring Team, however, which has for the past six years analyzed CAH quality using CMS Hospital Compare data (and produced widely disseminated annual reports on the national and state level), notes that the study fails to compare how transferred patients differ from those who stay at CAHs.

For example, it points to other studies, which have found that acute myocardial infarction patients who are not transferred are older, sicker, have more comorbidities, and are at higher risk for adverse outcomes.

Moreover, they not only disagree with the authors' assertion that "little is known about the quality of care" at CAHs, but say that outcome differences "likely reflect broader health care access issues in rural communities." They also argue that "hospitals with 100 beds differ significantly from CAHs with 25 or fewer beds and are not a valid comparison group."

All sides seem to agree, though, that there's room for quality improvement in CAHs. The University of Minnesota Rural Health Research Center/Flex Monitoring Team's statement says, "it is not news that CAHs have room for improvement on process of care quality measures; the Flex Monitoring Team reports have already shown that."

Foster says helping CAHs assess and improve their quality should be a national priority.

 "In that sense the conclusion of the authors about more work needing to be done and more national focus being paid to this is exactly right," she says.

In addressing accusations of a "big-city bias," Jha says he believes that "people who live in rural areas shouldn't have to choose between getting high-quality care and getting care locally."

"I think most critical access hospitals are trying to deliver that high-quality care," he says. "The fault is not with the critical access hospitals. It's with the national policy efforts that have not been as effective as they need to help these hospitals improve."

Read JAMA's study and tell us what you think.