The American Hospital Association took issue with the findings and said the "data presented now are not a reliable presentation of what is actually happening at critical access hospitals."
"CAHs and other small hospitals have engaged in a variety of practices designed to identify and rapidly transfer patients who could benefit from more aggressive interventions at nearby hospitals that have the capability of intervening. One reason for seeing a rise in mortality in some CAHs could be because the hospital may tend to keep patients that are too sick for transfer or not stable enough. As a result CAHs' data maybe skewed toward patients who are sicker," AHA said in an email exchange.
The contentious study also prompted an editorial rebuttal in the same issue of JAMA from Stanford University researcher John P.A. Ioannidis, MD, who wrote that "even if the differences in CAH vs. non-CAH mortality rates are genuine, this does not mean that policy makers should necessarily advocate for CAHs to collect and report performance data or to participate in quality improvement programs, change their payment mechanisms, or both."
"The study by Joynt et al can minimally inform such decisions. Trying to impose quality data collection and reporting in such hospitals that have already strained resources may actually do more harm than good. Even for non-CAHs, the evidence is tenuous that performance and quality initiatives do work."
Gary Tiller, CEO of Ninnescah Valley Health Systems, Inc. in Kingman, KS, which operates the 25-bed Kingman Community Hospital, says the study "has renewed my lack of faith in the Harvard School of Public Health."
"This is all much ado about nothing. There are a lot of ways to look at the data depending upon what you want to do with it," Tiller says.