Surgical quality gap narrows for critical-access hospitals versus other hospitals, JAMA study shows
Patients admitted to CAHs compared with non-critical access had no significant difference in 30-day mortality, lower Medicare expenses, study says.
A recent study published in JAMA suggests the gap in quality between critical access hospitals and non-critical access hospitals may not be as wide as originally thought.
The study looked at surgical outcomes for Medicare beneficiaries who underwent four common, less medically complex procedures. It found that patients admitted to critical access hospitals compared with non–critical access hospitals had no significant difference in 30-day mortality rates, showed decreased rates of serious complications and lower-adjusted Medicare expenditures.
The study results run counter to previous ones that seemed to show quality in critical access facilities was lacking. Authors for this most recent study pointed out previous investigations that looked at outcomes at CAHs for myocardial infarction, heart failure, and pneumonia showed worse mortality rates and decreased compliance with process measures of care. A follow up study that evaluated outcomes for the same conditions from 2002 to 2010 showed an increase in mortality rates, despite additional funding for quality improvements. Yet there had been no study dedicated to surgical outcomes for CAHs versus non-critical access facilities.
The JAMA study looked at outcomes for appendectomy, cholecystectomy, colectomy and hernia repair from 2009 to 2013. The goal was to compare those outcomes and associated Medicare payments at both critical access and non-critical access. These procedures are commonly performed at both types of facilities, and in fact represent the four most common general surgery inpatient procedures performed at CAHs, the study's authors wrote.
Results focused specifically on mortality rates and postoperative serious complications.
Data showed that CAHs and non-critical access facilities had no "statistically significant" differences in 30-day mortality rates, with CAHs showing a rate of 5.4 percent compared to 5.6 percent for non-critical access hospitals. CAHs also showed lower rates of in-hospital mortality, 2.9 percent versus 3.9 percent.
Additionally, CAH's showed showed significantly lower rates of serious postoperative complications, with 6.4 percent versus 13.9 percent for non-critical access facilities, as well as lower rates of overall complications, 17.5 percent versus 25.4 percent.
Finally, Medicare expenditures, though adjusted for patient factors and type of procedure, proved lower at CAH's than non-critical access at $14,450 versus $15,845. They also proved lower when the procedures' results were examined individually, the study showed.
However, critical access hospitals had higher rates of readmission after 30 days, than non-critical access facilities, 14.7 percent versus 13.3 percent. Data showed this to be true when measuring outcomes for the individual procedures.
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The authors did point out several factors to be considered when weighing these results. First, patients undergoing surgical procedures at CAH's were less likely to have common conditions that would increase their overall morbidity like diabetes, obesity and heart failure. This is likely because these facilities are able to select appropriate candidates before they operate. For this study, they also generally operated on fewer complex patients. In contrast, non-critical access facilities performed more emergency operations.
"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 authors wrote.
Additionally, the authors said that the CAH's involved with this study have sufficient resources and the capabilities to perform inpatient general surgery, likely more than the larger populations of CAH's.
Twitter: @BethJSanborn
