Comparison of Quality of Care Indicators: U.S. Urban and Rural Hospitals
Comparison of Quality of Care Indicators: U.S. Urban and Rural Hospitals
Objective: Two recent Institute of Medicine reports highlight that the quality of healthcare in the US is less than what should be expected from the world's most extensive and expensive healthcare system. This may be especially true for critical access hospitals since these smaller rural-based hospitals often have fewer resources and less funding than larger urban hospitals. The purpose of this paper was to compare quality of hospital care provided in urban acute care hospitals to that provided in rural critical access hospitals.
Design. Cross-sectional study analyzing secondary Hospital Compare data. T-test statistics were computed on weighted data to ascertain if differences were statistically significant (P = 0.01).
Setting: Centers for Medicare and Medicaid Services hospitals.
Participants: US Acute Care and Critical Access hospitals.
Main outcome measures: Differences between urban acute care hospitals and rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure and pneumonia.
Results: For 8 of the 12 hospital quality indicators the differences between urban acute care and rural critical access hospitals were statistically significant (P = 0.01). In seven instances these differences favored urban hospitals. One indicator related to pneumonia favored rural hospitals
Conclusions: Although this study focused on only three disease states, these are among the most common clinical conditions encountered in inpatient settings. The findings suggested that there may be differences in quality in rural critical access hospitals and urban acute care hospitals and support the need for future studies addressing disparities between urban acute care and rural critical access hospitals.
Two recent Institute of Medicine reports highlight that the quality of healthcare in the US is less than what should be expected from the world's most extensive and expensive healthcare system. Other studies also point out that the quality of American healthcare might be deficient and that many patients do not receive care consistent with the latest scientific knowledge or accepted best practice.
These reports and study findings stimulated interest for health agencies, consumers, and physicians to assess and improve healthcare quality. The response to date has focused primarily upon increased measurement in the form of reporting clinical indicator data in the US. Despite efforts to use this information to gauge quality and to improve outcomes, there is still uncertainty about the quality of hospital care and how they compare to each other. This may be especially true for the approximately 1200 rural critical access hospitals in the US because these smaller rural-based hospitals often have fewer resources and less funding than larger urban hospitals. Skilled personnel may also be an issue since only 10% of physicians serve rural populations and less than one-third the number of specialists per capita practice in rural settings versus urban settings. Compounding these factors are the challenges presented in caring for rural residents who tend to be older than urban dwellers, have higher rates of chronic illnesses, and exhibit poorer health behaviors, such as higher rates of smoking and obesity and lower rates of exercise than their urban counterparts. Given these combinations of circumstances it is hard not to speculate that the quality of rural hospital care might not compare favorably to urban hospitals.
Previous studies focusing on one disease state such as acute myocardial infarction (AMI) supports the contention that healthcare quality in rural settings might be inferior to that found in urban settings. Researchers using indicators such as personnel, equipment, organizational systems and quality improvement activities found that patients experiencing an AMI in rural hospitals in Kansas were less likely to receive standard care and tended to have worse outcomes compared with their urban counterparts. Another study examining rural hospital Medicare patients with an AMI had similar findings with a significantly higher adjusted 30-day post AMI death rate than those in urban hospitals. In contrast, other studies have documented superior outcomes in rural settings for common procedures such as low-risk obstetrics and a lower incidence overall of medical errors or injuries suggesting that there may not be a disparity in rural hospital care.
Unfortunately, most previous studies exploring the differences in outcomes of patients hospitalized in rural hospitals are limited because they either focused on one geographical region, a single disease state, a particular segment of the population, or examined rural regions alone with no comparisons to urban or metropolitan populations. Other studies used surrogate measures for quality of care such as staffing, organizational systems and admission rates which have not always been proven to be accurate measures of clinical outcomes.
The purpose of this research was to compare the quality of hospital care provided in urban acute care hospitals to that provided in rural critical access hospitals using a national database. This study builds upon existing work by comparing quality of care indicators that have been proven to decrease morbidity and mortality for AMI, heart failure and pneumonia. The disease states, cardiovascular disease and pneumonia, examined in this study were of particular interest because some of the most effective and immediate treatments are equally accessible in rural as well as urban hospitals, making them a useful standard for assessing quality of care.
Abstract and Introduction
Abstract
Objective: Two recent Institute of Medicine reports highlight that the quality of healthcare in the US is less than what should be expected from the world's most extensive and expensive healthcare system. This may be especially true for critical access hospitals since these smaller rural-based hospitals often have fewer resources and less funding than larger urban hospitals. The purpose of this paper was to compare quality of hospital care provided in urban acute care hospitals to that provided in rural critical access hospitals.
Design. Cross-sectional study analyzing secondary Hospital Compare data. T-test statistics were computed on weighted data to ascertain if differences were statistically significant (P = 0.01).
Setting: Centers for Medicare and Medicaid Services hospitals.
Participants: US Acute Care and Critical Access hospitals.
Main outcome measures: Differences between urban acute care hospitals and rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure and pneumonia.
Results: For 8 of the 12 hospital quality indicators the differences between urban acute care and rural critical access hospitals were statistically significant (P = 0.01). In seven instances these differences favored urban hospitals. One indicator related to pneumonia favored rural hospitals
Conclusions: Although this study focused on only three disease states, these are among the most common clinical conditions encountered in inpatient settings. The findings suggested that there may be differences in quality in rural critical access hospitals and urban acute care hospitals and support the need for future studies addressing disparities between urban acute care and rural critical access hospitals.
Introduction
Two recent Institute of Medicine reports highlight that the quality of healthcare in the US is less than what should be expected from the world's most extensive and expensive healthcare system. Other studies also point out that the quality of American healthcare might be deficient and that many patients do not receive care consistent with the latest scientific knowledge or accepted best practice.
These reports and study findings stimulated interest for health agencies, consumers, and physicians to assess and improve healthcare quality. The response to date has focused primarily upon increased measurement in the form of reporting clinical indicator data in the US. Despite efforts to use this information to gauge quality and to improve outcomes, there is still uncertainty about the quality of hospital care and how they compare to each other. This may be especially true for the approximately 1200 rural critical access hospitals in the US because these smaller rural-based hospitals often have fewer resources and less funding than larger urban hospitals. Skilled personnel may also be an issue since only 10% of physicians serve rural populations and less than one-third the number of specialists per capita practice in rural settings versus urban settings. Compounding these factors are the challenges presented in caring for rural residents who tend to be older than urban dwellers, have higher rates of chronic illnesses, and exhibit poorer health behaviors, such as higher rates of smoking and obesity and lower rates of exercise than their urban counterparts. Given these combinations of circumstances it is hard not to speculate that the quality of rural hospital care might not compare favorably to urban hospitals.
Previous studies focusing on one disease state such as acute myocardial infarction (AMI) supports the contention that healthcare quality in rural settings might be inferior to that found in urban settings. Researchers using indicators such as personnel, equipment, organizational systems and quality improvement activities found that patients experiencing an AMI in rural hospitals in Kansas were less likely to receive standard care and tended to have worse outcomes compared with their urban counterparts. Another study examining rural hospital Medicare patients with an AMI had similar findings with a significantly higher adjusted 30-day post AMI death rate than those in urban hospitals. In contrast, other studies have documented superior outcomes in rural settings for common procedures such as low-risk obstetrics and a lower incidence overall of medical errors or injuries suggesting that there may not be a disparity in rural hospital care.
Unfortunately, most previous studies exploring the differences in outcomes of patients hospitalized in rural hospitals are limited because they either focused on one geographical region, a single disease state, a particular segment of the population, or examined rural regions alone with no comparisons to urban or metropolitan populations. Other studies used surrogate measures for quality of care such as staffing, organizational systems and admission rates which have not always been proven to be accurate measures of clinical outcomes.
The purpose of this research was to compare the quality of hospital care provided in urban acute care hospitals to that provided in rural critical access hospitals using a national database. This study builds upon existing work by comparing quality of care indicators that have been proven to decrease morbidity and mortality for AMI, heart failure and pneumonia. The disease states, cardiovascular disease and pneumonia, examined in this study were of particular interest because some of the most effective and immediate treatments are equally accessible in rural as well as urban hospitals, making them a useful standard for assessing quality of care.
