Abstract 16615: Changes in Outcomes at Critical Access Hospitals in the U.S.: Implications for Improving Rural Healthcare

Abstract

Critical Access Hospitals (CAHs) are small, rural hospitals that provide healthcare to some of the nation’s most vulnerable populations. Since the inception of the CAH program, these hospitals have been largely excluded from most national quality improvement policies and programs. Whether they have experienced gains in outcomes for common cardiovascular diseases that are comparable to those realized at other hospitals is largely unknown. We used Medicare inpatient data from 2002 through 2010, and compared trends in 30-day mortality rates over time for acute myocardial infarction (AMI), congestive heart failure (CHF), and stroke between CAHs and other hospitals providing acute care in the U.S.. Accounting for baseline differences in hospital characteristics, including hospital size and rurality, CAHs had comparable mortality rates to non-CAHs in 2002: AMI (16.9% vs 18.6%, p=0.06) CHF (11.1% vs. 11.0%, p=0.76), and stroke (22.0% vs. 20.7%, p=0.13). Over the next 8 years, however, CAHs lagged behind non-CAHs in their rate of improvement for all three conditions (Figure). For AMI, mortality increased 0.5% per year in CAHs, but fell 0.3% per year in non-CAHs (difference in change 0.8%, p<0.001). For CHF, mortality increased 0.3% per year in CAHs, but remained stable in non-CAHs (difference in change 0.3%, p<0.001); for stroke, mortality stayed stable in CAHs but dropped 0.2% per year in non-CAHs (p=0.16). As a result, by 2010, CAHs had substantially higher mortality rates for all three conditions: for AMI, 20.7% at CAHs vs 16.3% at non-CAHs (p<0.001); for CHF, 13.3% at CAHs vs 11.0% at non-CAHs (p<0.001); and for stroke, 21.4% at CAHs vs 19.1% at non-CAHs (p<0.001). Over the past decade, while most of the nation’s hospitals saw important improvements in outcomes for cardiovascular disease, mortality rates have worsened at CAHs. Given that the gap between CAHs and non-CAHs appears to be widening over time, we need new policy initiatives to help these institutions improve.