A designation of critical access hospital was developed about 20 years ago to help ensure access to care for the more than 59 million people living in rural areas of the United States. The Medicare Rural Hospital Flexibility Program was established because policymakers were worried that many hospitals would close due to financial hardship. The critical access hospital provision entitled hospitals to higher reimbursements if they had fewer than 25 inpatient beds and were located more than 35 miles away from another hospital.

“Many hospitals enrolled in the Medicare Rural Hospital Flexibility Program, but concerns emerged about the resultant Medicare budget growing to more than $9 billion annually,” explains Andrew M. Ibrahim, MD. This led government agencies and advisory groups to call for modifications and perhaps elimination of the critical access designation. Advocates, however, argue that such changes could disrupt the communities that heavily rely on critical access hospitals for healthcare.

An Important Comparison

Dr. Ibrahim and colleagues had a study published in JAMA that evaluated outcomes and costs among Medicare beneficiaries undergoing operations at critical access and non–critical access hospitals. The investigators retrospectively reviewed more than 1.6 million Medicare beneficiary admissions to critical access hospitals and non–critical access hospitals for one of four common types of surgeries—appendectomy, cholecystectomy, colectomy, and hernia repair—between 2009 and 2013. After adjusting for patient factors, admission type, and type of operation, they then compared 30-day mortality and rates of serious postoperative complications, such as myocardial infarction, pneumonia, or acute renal failure. Hospital costs were assessed using price-standardized Medicare payments during hospitalization.

According to the results, patients undergoing surgery at critical access hospitals were less likely than those receiving care at non–critical access hospitals to have chronic medical problems, including heart failure, diabetes, and obesity. “Patients treated at critical acess hospitals, on average, appeared to be less medically complex,” adds Dr. Ibrahim. After adjusting for patient factors, critical access and non–critical access hospitals had no statistically significant differences in 30-day mortality (Table). However, non–critical access hospitals had significantly higher rates of serious complications when compared with critical access hospitals. Conversely, critical access hospitals had higher rates of readmission within 30 days than non–critical access hospitals. Repeat subgroup analysis for each of the procedures assessed in the study demonstrated similar findings.

In addition, the analysis showed that Medicare expenditures were nearly $1,400 lower at critical access hospitals than non–critical access hospitals after the research team adjusted for patient factors and procedure type. Despite the reimbursement structure for critical access hospitals, there was no evidence of higher expenditures for the four surgical procedures assessed in the study.

Examining Possible Reasons

“Our findings help inform us about the valuable role critical access hospitals serve in the country’s healthcare system,” says Dr. Ibrahim. He notes that his study group’s data go beyond findings of previous research because they assessed a wider range of surgical outcomes and because they evaluated all critical access hospitals in the U.S. performing four common surgical procedures in Medicare beneficiaries.

Although the study did not identify a clear mechanism for the contrast between medical and surgical outcomes, Dr. Ibrahim and colleagues reported that there are several possible explanations for the results. For example, critical access hospitals have the opportunity to select appropriate candidates for surgery before deciding whether to operate. “Critical access hospitals generally operated on fewer complex patients and had relatively low postoperative transfer rates,” Dr. Ibrahim says. The study also only included critical access hospitals that perform these operations, which is likely a subset of relatively well-resourced critical access hospitals. Furthermore, the data of higher readmissions may reflect limited access to post-discharge care that has been previously described in rural settings.

Analyzing Implications

“Patients in rural settings are sometimes reluctant to travel for surgical care, even when they are told it could improve their outcome,” says Dr. Ibrahim. “We need healthcare systems architects to organize service lines across regions and structure payment policies that secure safe, local surgical care.” This can allow rural clinicians to accommodate patient preferences without putting them at higher risk when undergoing common operations.

With many hospitals partnering with larger institutions to coordinate care, Dr. Ibrahim says there are opportunities to further improve patient outcomes after common surgeries. “Creating a network relationship with larger facilities located in the nearest metropolitan area could facilitate the important role they are already playing in triaging and transferring patients to higher levels of care when needed,” he says. “Medically complex patients can be referred to surgery at larger medical centers, but those who are relatively healthy are likely to do well after their operation at smaller, rural centers.” He adds that more research is needed to determine how best to manage moderately complex patients who undergo relatively common and other surgical procedures.



Andrew M. Ibrahim, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.