Critical-access hospitals, which are required to have no more than 25 beds, serve primarily rural areas and are exempt from Medicare's prospective payment system.
While mortality rates dipped 0.2% a year since 2002 at non-critical access hospitals, they rose 0.1% a year at critical-access hospitals, the authors said. There was a similar pattern for each of the three conditions studied. By 2010, critical-access facilities' overall mortality rate was 13.3%, compared with 11.4% for other acute care hospitals.
“Given the substantial challenges that (critical-access hospitals) face, new policy initiatives may be needed to help these hospitals provide care for U.S. residents living in rural areas,” the study's authors wrote.
While quality at critical-access hospitals has long been a concern, little has been known about their progress in improving patient outcomes up to this point, researchers said.
The researchers identified a number of potential reasons why critical-access hospitals have not registered the same gains as have other hospitals. Critical-access facilities are exempt from participation in federal quality reporting and improvement programs, some of which reward or penalize hospitals based on outcomes. The way they are paid—through cost-based reimbursement—could reduce incentives to improve quality, the authors said.
Also, critical-access hospitals face challenges adopting the advanced technology systems that many other hospitals use to bolster quality improvement efforts.
“New interventions, such as close partnerships with larger institutions, use of technologies such as teleconsultation, or programs that help clinicians at (critical-access hospitals) determine which patients may need a higher level of care, may provide benefit for patients at these hospitals,” they wrote.
Despite an overall uptick in mortality during the past decade, more than 400 critical-access hospitals reduced mortality rates, particularly in areas with slightly higher median incomes, according to the study.
Although critical-access hospitals do not participate in the CMS' quality initiatives, a number of other organizations have spearheaded specialized projects aimed at boosting outcomes at small hospitals. The North Dakota Critical Access Hospital Quality Network, housed at the Center for Rural Health at the University of North Dakota, Grand Forks, provides a forum for such hospitals to exchange best practices and collaborate on improvement efforts.
A similar group, the Maine CAH Patient Safety Collaborative, works with 16 critical-access hospitals on quality and safety initiatives.
