The Journal of the American Medical Association Surgery (JAMA) misunderstood rural health again. JAMA seems to have resumed its inquiry into critical access hospitals (CAHs) in an article released today, titled “Transfer Rates and Use of Post-Acute After Surgery at CAH vs Non-CAHs,” This article won’t surprise those who have already come to expect sweeping conclusions based on minimal evidence.
Bottom line, it is time for non-rural health researchers to stop exaggerating their claims on CAHs.
The article examines the differences in transfer rates between CAHs and non-CAHs for six surgical procedures commonly performed in each (hip and knee replacements, hip fracture repair, colorectal cancer resection, cholecystectomy and transurethral resection). The data revealed that after adjustment for patient and hospital factors, three of the surgical procedures (hip replacement, colorectal cancer resection and cholecystectomy) had a higher likelihood of transfer by a CAH versus a non-CAH. Simply put, the authors describe these procedures as being "commonly performed in CAHs," but they only identified 22,543 cases in all CAHs in their sample, even using five years of data and six procedures. These 22,543 cases in CAHs only account for 2 percent of all cases for these procedures, while non-CAHs account for 98 percent of total cases.
To add insult to injury, the paper does not provide the number of cases per procedure in CAHs, nor does it indicate how many of the CAHs in the sample even had any cases of each procedure. Many CAHs don't do inpatient surgery, and many don’t do one or more of these procedures. For the sake of argument, if you divide the 22,543 CAH cases by the number of CAHs in the sample (446) you get an average of 50 cases per CAH for all six procedures for all five years, or 10 cases per CAH per year.
We are talking about a very small number of CAH cases with these procedures relative to non-CAHs and an even smaller number of cases that are transferred from the CAHs.
The authors say that “from a quality perspective, higher transfer rates at CAHs after the often-elective procedures examined herein raise concerns regarding the relative frequency and/or severity of post-operative complications at these facilities.” Could it be that if the analysis examined not the inter-facility transfers between non-CAHs, but the intra-facility transfers following these six surgical procedures could yield a different result? For example, in large non-CAHs, a patient whose condition deteriorates and is transferred from a general surgical unit to a surgical intensive care unit could be more accurate. Why would a large hospital ever need to do an inter-facility transfer? I would have expected the difference to be much greater, actually.
Another point the authors make is “if the higher transfer rates reflect practice patterns driven by the length-of-stay requirements at CAHs rather than by complications, then our findings suggest that an unintended consequence of this policy may be avoidable fragmentation of care for surgical patients treated in CAHs.” This finding would support NRHA’s argument for the repeal of the 96-hour condition of payment requirement currently enforced by CMS.
Finally, last month iVantage released data regarding the cost and quality of services provided in rural communities. This executive summary and infographic provide a summary of the lower costs and equal to or greater quality of health care found in rural communities versus urban.
CAHs and rural communities provide a model for health care delivery in the United States and should be celebrated for these contributions, not made out to be the source of our problems regarding dollars invested by the federal government.