Certainly rural patients are different from urban patients, but in most research the people who do the best are suburbanites. I don't think this is driven by simply the fact that rural patients are so much sicker and so much older because we control for things like age and diabetes. We don't perfectly control for things like smoking or obesity because we can't measure those. But I don't think the changes over time have been so vast that that is what we are looking at here.
HLM: How significant is the 1.8% difference in mortality rates?
KJ: What it is telling us is that we have left these hospitals behind because 1.8% of the absolute mortality rate is 1 in 50 people. That is more than 10% of the actual rate, so in clinical trial speak it is a significant relevant risk.
But what is important here is not the specific numbers, but recognizing that the effort to carve these hospitals into a separate program than the remainder of the hospitals in the country has not done them any favors and it hasn't done any favors for the people seeking care at these hospitals.
If you live in rural Maine or rural Nevada and you present to your local hospital having a heart attack in this day and age we should expect that a system of hospital care will figure out how to treat that patient as optimally as possible.
What this [research] points out to me is not so much a problem with the hospitals as it is a systems problem. It's not realistic to expect that these small hospitals should have the same resources as other hospitals do. Having a 24-hour cardiac cath lab in a hospital with 10 beds doesn't make any sense.
But if you live out there and you have a heart attack, we should have a system that gets you where you need to be. With telemedicine and other technologies it seems like as a system we could do better for rural patients.
It's not that these hospitals are doing a bad job. It's that we are asking them to do an impossible job if they are not supported. I am a cardiologist. I work in an academic medical center. The resources that I have at my disposal at an academic medical center are completely different from the resources that a physician has working at a critical access hospital. I cannot imagine how hard that job must be.