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Medicare mortality higher at critical access hospitals


In an analysis that included data on more than 10 million Medicare beneficiaries admitted to acute care hospitals with myocardial infarction, heart failure or pneumonia between 2002 and 2010, 30-day mortality rates for those admitted to critical access hospitals increased during this time period compared with patients admitted to other acute care hospitals.

In background information for the study, which was published in the April 3 issue of the Journal of the American Medical Association, researchers noted that more than 60 million Americans in rural areas face challenges in accessing high-quality inpatient care. Congress created the critical access hospital designation in 1997 in response to increasing rural hospital closures. By 2010, nearly one in four of the nation’s hospitals were critical access hospitals. “These hospitals are at high risk of falling behind with respect to quality improvement, owing to their limited resources and vulnerable patient populations,” the authors wrote. “How they have fared on patient outcomes during the past decade is unknown.”

To investigate, Karen E. Joynt, MD, MPH, of the Harvard School of Public Health in Boston, and colleagues conducted a study to evaluate trends in mortality for patients receiving care at CAHs and compared these trends with those for patients receiving care at non-CAHs. The study included data from Medicare fee-for-service patients admitted to U.S. acute care hospitals with acute MI (1,902,586 admissions), heart failure (4,488,269 admissions) and pneumonia (3,891,074 admissions) between 2002 and 2010.

In 2010, 1,264 of 4,519 (28%) of U.S. hospitals providing acute care services to Medicare beneficiaries and reporting hospital characteristics to the American Hospital Association were designated as CAHs.

The researchers found differences in trends in 30-day mortality rates over time between CAHs and non-CAHs for the three conditions examined. After accounting for teaching status, ownership, region, “rurality,” location and local physician supply, the researchers found that composite baseline mortality was similar between CAHs and other hospitals.

However, the researchers wrote, mortality rates increased at CAHs at a rate of 0.1% per year between 2002 and 2010, whereas at non-CAHs they decreased by 0.2% for year. Given the 0.3% annual difference in change of mortality, by 2010, CAHs had higher overall mortality rates (13.3.% vs. 11.4%). In total, the researchers calculated, CAH admissions were associated with 10.4 excess deaths per 1,000 admissions during the study period.

The researchers noted that although CAHs had higher mortality rates by 2010 for each of the conditions examined, the absolute difference was only 1.8%. Patterns were similar for each of the three conditions individually. When comparing CAHs with other small, rural hospitals, similar patterns were found.

“Given the substantial challenges that CAHs face, new policy initiatives may be needed to help these hospitals provide care for U.S. residents living in rural areas,” the authors concluded.

The study abstract is available at


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