Small, Rural Hospitals Might Be Safer, More Cost Effective

By Christine Kern, contributing writer

Surprising findings show local care might be best for straightforward surgical cases.

When comparing outcomes for procedures performed in small rural critical access hospitals and their larger, urban non-critical access counterparts, a recent study posted by JAMA returned some surprising results: small, rural hospitals might actually be safer and more cost-effective.

The study, Association of Hospital Critical Access Status With Surgical Outcomes and Expenditures Among Medicare Beneficiaries, reviewed 1.6 million Medicare beneficiary admissions to critical access hospitals and non-critical access hospitals for one of four common surgical procedures (appendectomy, cholecystectomy, colectomy, and hernia repair) between 2009 and 2013. The researchers compared risk-adjusted outcomes, adjusted for patient factors, admission type, and type of operation.

The data yielded several surprises according to Science Daily, including:

• The risk of dying within 30 days of the operation was the same whether a patient had surgery at a critical access hospital or a larger hospital.
• The risk of suffering a major complication after surgery, such as a heart attack, pneumonia or kidney damage, was lower at critical access hospitals.
• Patients who had their operation at a critical access hospital cost the Medicare system nearly $1,400 less than patients who had the same operation at a larger hospital, after differences in patient risk and pricing were accounted for.
• The patients who had these operations at critical access hospitals were healthier to begin with than patients treated elsewhere, suggesting that critical access hospital surgeons are appropriately selecting surgical patients who can do well in a small rural setting, and triaging more complex patients to larger centers.
• But even after the researchers corrected for differences in pre-operation health, the critical access hospitals still had equal or better outcomes.

“From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care,” says Andrew Ibrahim, M.D., first author of the new study and a VA/Robert Wood Johnson Clinical Scholar at the U-M Medical School.

The study concluded there was no significant difference in 30-day mortality rates for patients admitted to critical access hospitals compared with non-critical access hospitals, and that they also saw decreased risk-adjusted serious complication rates and lower-adjusted Medicare expenditures, but were less medically complex.

Senior author Justin Dimick, M.D., MPH. added, “For many years, surgeons have debated whether we should concentrate surgery in a subset of our larger hospitals. The downside of this approach is that patients have to travel far from home for surgery, especially those living in remote areas. While it may make sense to travel to a higher volume hospital for a few of the most complex operations, this study shows that having surgery locally is safe for many of our most common surgical procedures.”