"We did a whole series of analyses to try to understand what the impact of the transfer situation was," he says, adding that the paper acknowledges that CAHs transfer many of their patients. "So we did a series of what's called sensitivity analyses where we tried to look at what impact that had. What if you included the transfer patients; what impact would that have on our outcomes? What if you excluded the transfer patients? We looked in a variety of different ways to try to understand the transfer situation. And the bottom line was it didn't make a big difference in terms of the outcomes. Critical access hospitals still had worse outcomes, no matter how you treated the transfer patients in the analysis."
The University of Minnesota Rural Health Research Center/Flex Monitoring Team, however, which has for the past six years analyzed CAH quality using CMS Hospital Compare data (and produced widely disseminated annual reports on the national and state level), notes that the study fails to compare how transferred patients differ from those who stay at CAHs.
For example, it points to other studies, which have found that acute myocardial infarction patients who are not transferred are older, sicker, have more comorbidities, and are at higher risk for adverse outcomes.
Moreover, they not only disagree with the authors' assertion that "little is known about the quality of care" at CAHs, but say that outcome differences "likely reflect broader health care access issues in rural communities." They also argue that "hospitals with 100 beds differ significantly from CAHs with 25 or fewer beds and are not a valid comparison group."
All sides seem to agree, though, that there's room for quality improvement in CAHs. The University of Minnesota Rural Health Research Center/Flex Monitoring Team's statement says, "it is not news that CAHs have room for improvement on process of care quality measures; the Flex Monitoring Team reports have already shown that."