Rural hospitals are safe for common operations

surgeons wash hands

Healthy Americans living in rural areas may want to consider having surgery at a nearby hospital rather than travel to a larger urban hospital.

Researchers analyzed data from 1.6 million hospital stays for four common operations—gallbladder removal, colon surgery, hernia repair, and appendectomy. They compared what happened to patients covered by Medicare who had their operations at 828 smaller hospitals, known as critical access hospitals, with data from patients treated at more than 3,600 larger hospitals.

Surprising findings:

  • The risk of dying within 30 days of the operation is the same at both types of hospitals.
  • The risk of suffering a major complication after surgery, such as a heart attack, pneumonia, or kidney damage, is lower at critical access hospitals.
  • Patients who have their operation at a critical access hospital cost the Medicare system nearly $1,400 less than patients who have the same operation at a larger hospital, after accounting for differences in patient risk and pricing.
  • Patients who have these operations at critical access hospitals are healthier to begin with than patients treated elsewhere, suggesting that critical access hospital surgeons are appropriately selecting surgical patients who can do well in a small rural setting, and triaging more complex patients to larger centers.
  • Even after researchers corrected for differences in pre-operation health, critical access hospitals still have equal or better outcomes.

The findings are timely because of the current debate over whether to change the national policies that designate critical access hospitals, and determine how much they get paid for medical and surgical services, researchers say. Hundreds of these hospitals are in danger of closing, threatening local access to care for millions of Americans.

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Currently, the Medicare system essentially subsidizes them by paying them slightly more than the total cost of care, in order to ensure they can stay financially afloat to serve rural areas. Even still, dozens have closed in recent years.

Studies of common medical conditions like heart attacks and pneumonia at critical access hospitals have raised questions about how well they care for patients with these conditions. The new study is the first comprehensive look at the surgical care they provide.

“From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care,” says first author Andrew Ibrahim, a VA/Robert Wood Johnson Clinical Scholar at the University of Michigan Medical School.

“The goal of the rural surgeon is best care nearest home. Data to assure that the care in rural centers is both safe and cost effective is critical in the decisions the profession faces in providing care to the 20 percent of the US population living in truly rural environments,” says Tyler Hughes, one of two surgeons at the critical access McPherson Hospital in McPherson, Kansas and a director of the American Board of Surgery.

“This study gives credence to what rural surgeons long suspected—that well-done rural surgery is safe and cost effective.”

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“For many years, surgeons have debated whether we should concentrate surgery in a subset of our larger hospitals. The downside of this approach is that patients have to travel far from home for surgery, especially those living in remote areas,” says Justin Dimick, professor of surgery and a senior author of the study that is published in the Journal of the American Medical Association. “While it may make sense to travel to a higher volume hospital for a few of the most complex operations, this study shows that having surgery locally is safe for many of our most common surgical procedures.”

Other findings:

  • Less than 5 percent of surgery patients at critical access hospitals get transferred to larger hospitals, compared with more than a quarter of patients treated for non-surgical issues and studied by other teams.
  • Critical access hospital surgery patients are less likely to use skilled nursing facilities after their operations.
  • Complex operations such as esophagus or pancreas removal are performed so rarely at critical access hospitals they were not included in the study.

Under the original provision established by the Medicare Rural Hospital Flexibility Program, hospitals are eligible for critical access designation if they have less than 25 inpatient beds and are more than 35 miles away from another hospital.

By meeting these criteria and undergoing critical access designation, hospitals are paid 101 percent of reasonable costs. They are also exempt from certain other limits on Medicare payment that non-critical access hospitals are subject to. Physicians who practice at critical-access hospitals are also able to receive 115 percent of the usual payment for traditional Medicare patients.

The new research is based on data from the Medicare Provider Analysis and Review file from 2009 to 2013, after nearly all of the current 1,332 critical access hospitals underwent designation.

The Robert Wood Johnson Foundation, the US Department of Veterans Affairs, and the National Institute on Aging funded the work.

Source: University of Michigan

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