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Critical access hospitals (CAH), a US initiative, are defined as no more than 25 acute care beds and more than 35 miles from the nearest hospital. The advantage of being designated a CAH is a transfer from activity to cost-based funding, and subsequently improving viability. The initiative has been successful in improving activity and reducing closures in these small hospitals, but as they are not required to report to national quality programs, the quality of patient care has not been reported. All patients admitted to 4738 Medicare fee-for-service US hospitals with AMI, CHF, and CAP in 2008-2009 had outcomes compared if they where admitted to a CAH (n=1268) vs other hospital (n=3470).

The authors compared summary statistics for hospital, demographic, and patient characteristics.

They then adjusted for factors outside a hospitals control (ie region, income), before applying a multivariate regression model looking at variables that may explain difference in outcome. Were the hospitals different? As expected CAH's are small (median beds=18), and are in lower incomes areas, with a higher proportion of Medicare patients. The patients admitted to CAH's with the index diseases were older, with a higher incidence of diabetes and depression, but a lower incidence of hypertension and kidney disease. They were more likely to be transferred to another acute care hospital, and had lower length of stays. The CAH's had fewer resources (presence of an ICU, cardiac cath or surgery ability, nurse staffing levels, specialist supply). CAH's also had lower performance in process of care. How did the patients do? In all 3 categories CAH's had significantly higher 30-day risk adjusted mortality.

These differences in mortality persisted after building in potential explanatory variables (eg rurality) into the model. Summary and editorial These small, under-resourced hospitals have worse outcomes. The authors suggest solutions that deal with staffing, expertise, and links to acute care hospitals through staff rotations, telemedicine, and financial rewards. The accompanying editorial comments on the disparity between rural and urban based health outcomes, and the measures (like CAH) to address this. Like the authors of the study, they call for exploration of strategies to improve quality and outcomes for patients in CAH's, with a focus on academic partnerships, telemedicine, protocol-driven health care etc. Can this be applied outside the US? I am unaware of research examining the resources and outcomes of patients admitted to Australian hospitals based on rurality. Although we don't have CAH's, it seems likely that the same divide in resources, and therefore outcomes, exists in this large, isolated country.