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Do Rural Patients Receive the Same Quality Care as City Dwellers? A Look at the Data

 

A new study featured in the British Medical Journal has added to the ongoing debate over quality differences between rural and non-rural hospitals, concluding that patients who visited EDs at hospitals with low admission rates (which were disproportionately rural) were more likely to die within seven days. While it doesn’t investigate if the deaths were preventable, some media outlets have used the study to suggest rural hospitals lag behind urban or academic medical centers in terms of care delivery and effectiveness. A review of Definitive Healthcare data shows that rural hospitals do perform worse than all other hospitals on several Centers for Medicare & Medicaid Services (CMS) and Agency for Healthcare Research and Quality (AHRQ) measures, even though they have a healthier patient base.

Rural hospitals have worse mortality rates than all other hospitals for four out of five common life-threatening conditions: pneumonia, stroke, COPD, heart failure, heart attack. Only mortality rates for stroke are slightly lower. The greatest difference lies with COPD, reaching a rate 19.8 percent at rural hospitals compared to 7.9 percent at other facilities. Previous studies have attributed the disparity to longer wait times prior to treatment during emergencies and lower rates of stent placement. In addition, other reviews have suggested that rural patients are more likely than those in urban settings to have severe forms of the condition, leading to worse outcomes. For the other conditions, though, the cause is less clear, though transportation difficulties and fewer available specialists may play a role.

One interesting finding is that rural hospitals have superior readmission rates for the five conditions, with the exception of stroke. A possible explanation is their comparatively low median case mix of 1.07, compared to 1.57 at urban and suburban hospitals. Other research has noted that rural providers have fewer barriers to care coordination given that a single company can own the majority of care locations and employ the most providers in a rural county that may only have a single hospital. Limited physician choice also encourages patients to stay within an established provider network. However, the all-cause readmission rates for both groups are nearly identical, suggesting that rural hospitals may be focusing their reduction efforts almost exclusively on the most serious common conditions.

Median Rates of Mortality and Readmissions by Condition and Hospital Setting, 2016

Rural Hospitals All Other Hospitals
Mortality
Rate
Readmission
Rate
Mortality
Rate
Readmission
Rate
Pneumonia 16.8% 12.4% 16.1% 17.2%
Stroke 12.3% 16.5% 12.5% 14.6%
COPD 19.8% 15.5% 7.9% 20.0%
Heart Failure 21.8% 14.3% 11.8% 21.9%
Heart Attack 16.7% 8.0% 13.9% 16.9%
All-Cause Readmission Rate 15.5% 15.6%

Source: Definitive Healthcare data

When AHRQ measures are taken into account, rural hospitals still have worse scores, but not in every category. The median rural hospital had a higher incidence of collapsed lungs and accidental cuts and tears, but had slightly better rates of serious blood clots after surgery and far fewer wound splits than other hospitals. The fact that most rural hospitals don’t perform major or complex surgeries could explain the difference. It’s important to note, however, that the vast majority of the scores come from only about half of all rural hospitals and very few critical-access facilities are included. Not all hospitals have enough case volume or admissions to report figures to the AHRQ, which bases its rates on cases per 1000 discharges. Even rural hospitals that do submit data tend to have far fewer admissions than non-rural facilities that do the same (2,279 compared to 8,728), which effectively magnifies the impact of outlier medical events or patient cases on their scores.

Patient Characteristics and AHRQ Median Figures by Hospital Setting, 2016

Rural Hospitals All Other Hospitals
Case Mix 1.07 1.57
Major Complication/Co-morbidity Rate 47% 56%
Wound Splits After Surgery 0.47 2.22
Serious Blood Clots After Surgery 4.68 4.78
Accidental Cuts and Tears 2.25 1.37
Collapsed Lung 1.39 0.40

Source: Definitive Healthcare data

The suggestion that rural hospitals offer inferior care in the past has been met with serious opposition from advocacy groups, who usually argue that rural health care brings its own set of unique challenges. Responses to a 2011 study critical of rural hospital performance pointed out that quality scores had been gradually improving since 2005 and questioned if traditional CMS quality measures could be meaningfully applied to rural facilities, pointing instead to sociodemographic factors and primary drivers of patient outcomes. However, as others have explained, patients should expect to receive the same quality care as they could find in a large city, and regardless of the exact reason, the data shows that rural hospitals certainly have room to improve.

Definitive Healthcare has the most up-to-date, comprehensive and integrated data on over 7,700 hospitals, 1.4 million physicians, and numerous other healthcare providers. Our database allows users to search by and report on a wide variety of quality metrics.

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