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Rural hospitals fall short in heart, pneumonia care

NEW YORK (Reuters Health) - The small hospitals many rural Americans rely on for emergency care may fall short when it comes to treating heart problems and pneumonia, a new study finds.

The study, published in the Journal of the American Medical Association, focused on so-called critical access hospitals (CAHs) -- small hospitals, usually located in remote areas, that get special Medicare reimbursements to help them stay financially afloat.

Researchers found that older Americans treated at these hospitals for heart attack, chronic heart failure or pneumonia had poorer survival rates in 2008-2009 than their counterparts seen at other U.S. hospitals.

The designation of "critical access hospital" was created by a 1997 law intended to stem the tide of hospital closings that began in the 1980s in rural areas of the U.S.

And the law does appear to have worked in that regard, said Dr. Karen E. Joynt, the lead researcher on the new study.

Hospital closures declined, and there are now about 1,300 critical access hospitals nationwide.

But the hospitals were also exempt from national reporting programs designed to track hospitals' quality of care, said Joynt, a researcher at the Harvard School of Public Health in Boston.

So they have been essentially "off the radar," she told Reuters Health, in national efforts to improve healthcare quality.

For their study, Joynt and her colleagues looked at data from 1,268 CAHs and 3,470 other U.S. hospitals. They found that the small, rural hospitals generally scored lower on "processes of care" measures for treating heart attacks, heart failure and pneumonia.

Standards set up by the national Hospital Quality Alliance state that, for example, heart attack patients should get aspirin when they arrive, prescriptions for aspirin and certain other medications at discharge, and counseling on smoking cessation if needed.

CAHs were in line with those guidelines 91 percent of the time, while other hospitals were 98 percent of the time.

What's more, rural patients had poorer survival rates. Among heart attack patients, 23.5 percent died within 30 days, versus 16 percent of patients treated at other hospitals.

When it came to heart failure -- a chronic condition in which the heart muscle can no longer pump efficiently enough to meet the body's needs -- 13 percent of CAH patients died within 30 days, versus 11 percent seen at other hospitals. A similar difference was seen among pneumonia patients: 14 percent, versus 12 percent, died within 30 days.

In general, rural patients tended to be older and sicker. But when Joynt's team accounted for those factors, rural patients still faced higher death risks.

Joynt was quick to point out that the study is not meant to "demonize" rural hospitals and the people who work at them.

"Patients in rural areas receive generally good care at these hospitals," Joynt said. She noted that surveys show that patients tend to give high ratings to CAHs -- in large part because they appreciate receiving care close to home.

"My hope is that this study will bring attention to the needs of rural hospitals," Joynt said.

"The more complex and technologically advanced medicine gets," she added, "the farther these hospitals will fall behind if we don't think of creative ways to integrate them more into the healthcare system."

Technology might offer a solution, according to Joynt. That could mean greater use of so-called telemedicine -- where staff at rural hospitals can consult with doctors at larger medical centers via video conferencing or other types of electronic communication.

But rural hospitals also seem to be falling short in low-tech ways, like providing aspirin and other medications to heart patients. Some of that, Joynt speculated, could be because these small hospitals simply lack a system to track their compliance with quality-care standards.

Dr. Martin S. Lipsky, who co-wrote an editorial published with the study, agreed that the findings are a "call" to look at ways to boost the quality of care at critical access hospitals.

"These are great places that fill an important need in their local communities," said Lipsky, of the University of Illinois College of Medicine in Rockford.

"But wherever you live in this country," he told Reuters Health, "you should feel confident that you have access to high-quality healthcare."

Lipsky agreed that technology and partnerships with larger, academic medical centers might help small rural hospitals improve care. So too could medical school programs that encourage more doctors to set up their careers in rural areas, he said.

Already, some surgery-training programs have, for example, set up "rural surgery" tracks, which train general surgeons in a broader range of simple procedures so that patients in rural areas will not have to be transferred to larger hospitals as often.

But what about people being treated at small rural hospitals right now? Lipsky pointed out that the absolute differences in death rates from heart failure and pneumonia in this study were small -- about 2 percentage points.

For some older adults in rural areas, he noted, the advantage of receiving treatment close to home, near family and friends, may be more important than the survival advantage they may or may not get from traveling to a distant hospital.

There are, however, certain treatments that will need to remain the domain of larger hospitals, Joynt pointed out.

Most small rural hospitals cannot realistically be expected to have cardiac catheterization labs, where doctors can perform invasive procedures to diagnose and possibly stop a heart attack in progress. In this study, less than one percent of CAHs had those facilities, versus 48 percent of other hospitals.

SOURCE: http://bit.ly/q115xv Journal of the American Medical Association, July 6, 2011.

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