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CAH Study Author Defends Surprising Data

John Commins, for HealthLeaders Media, April 3, 2013

A contentious study out this week suggests that mortality rates in critical access hospitals are worsening.

The basics of the study are thus: Researchers from Harvard Medical School and the Harvard School of Public Health examined administrative data from nearly 10 million Medicare fee-for-service admissions for acute myocardial infarction, congestive heart failure, and pneumonia between 2002–2010.

Comparing 30-day mortality rates of CAHs and non-CAHs in urban and rural settings, they found that while CAHs and non-CAHs had comparable mortality rates for the three conditions in 2002, CAHs gradually fell behind each year to the point where by 2010 CAHs mortality rates were 13.3% and non-CAH mortality rates were 11.4%, a difference of 1.8%.

In an interview, the study's lead author, Karen E. Joynt, MD, MPH, a cardiologist and an instructor at the Harvard Medical School and Harvard School of Public Health, offered her interpretation of the findings:

HLM: Were you surprised by your findings?

KJ: "We were actually. We had done a paper two years ago in which we looked at critical access hospitals in a cross-sectional fashion, a one-time look at outcomes and resources at critical access hospitals. We received quite a bit of feedback on that work from rural providers.

Many of them said it is not fair to look at one point it time because we have improved over time. You should look longitudinally. We thought that was a fair request and we did, and to our surprise we found that critical access hospitals had been performing, at least on mortality, relatively equivalently to non-CAHs earlier in the decade, but that over the past 10 years we have seen a separation of outcomes."

HLM: Are you confident that your study makes an apples-to-apples comparison?

KJ: Everyone on in the study is a Medicare patient over the age of 65 and not in a Medicare HMO. I don't think there is any reason to think that the difference between rural and non-rural patients, or more relevantly rural patients that go to critical access hospitals versus rural patients that go to other rural hospitals, that the differences in their characteristics should have changed so much over time as to make these results appear from nowhere.

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6 comments on "CAH Study Author Defends Surprising Data"


Dean Coddington (4/4/2013 at 3:43 PM)
Hi, Having worked with a number of critial access hospitals over the years, they have a different relationship with their communities. Older people, when sick, like to go to a place where they know the staff and where relatives can easily visit them. Therefore, they often resist transfer to nearby tertiary care centers in larger cities. I believe this is a key factor differentiating CAHs. DCC

JKuriyan (4/4/2013 at 10:56 AM)
The result is statistical and it is difficult to grasp the strengths and weaknesses without more details, like error bars and standard deviations. For example, how do the results vary amongst the rural CAHs? Are there urban CAHs that performed as poorly as rural CAHs? The author's recommendation of tele-health tools to bring urban experts to rural areas via the web sounds a little too simple. What's the point if the rural hospitals are not equipped to perform new and complex procedures? Transporitng them to urban hospitals may not be affordable or practical depending on the medical issue. Another example where capitalism struggles to meet medical needs of societies. There are solutions but they are unacceptable to US citizens. So let's move on! I am not sure if this was covered in the last page of the article - a full page Ad blocked it, an unnecessarily intrusive step that insults the readers and the belittles the contribution of the journalist.

Chris (4/4/2013 at 10:37 AM)
Answer to confusedreader, CAH is Critical Access Hospital