• Cyrus M Kosar, Lacey Loomer, Kali S Thomas, Elizabeth M White, Orestis A Panagiotou, and Momotazur Rahman.
• Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island.
• JAMA. 2020 Aug 4; 324 (5): 481487481-487.

ImportanceCritical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes.ObjectiveTo assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding.Design, Setting, And ParticipantsSerial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017.ExposureAdmission to a CAH vs non-CAH.Main Outcomes And MeasuresDischarge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses.ResultsThere were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, -0.99 [95% CI, -1.08 to -0.90]; P < .001). In 2011, the CAH vs non-CAH difference in diagnoses coded increased (P < .001 for interaction between CAH and year) to 9.27 vs 12.23 (difference, -2.96 [95% CI, -3.19 to -2.73]; P < .001). Adjusted mortality rates from the model with HCC were 13.52% for CAHs vs 11.44% for non-CAHs (percentage point difference, 2.08 [95% CI, 1.74 to 2.42]; P < .001) in 2007 and increased to 15.97% vs 12.46% (difference, 3.52 [95% CI, 3.09 to 3.94]; P < .001) in 2017 (P < .001 for interaction). Adjusted mortality rates from the model without HCC were not significantly different between CAHs and non-CAHs in all years except 2007 (12.19% vs 11.74%; difference, 0.45 [95% CI, 0.12 to 0.79]; P = .008) and 2010 (12.71% vs 12.28%; difference, 0.42 [95% CI, 0.07 to 0.77]; P = .02).Conclusions And RelevanceFor rural Medicare beneficiaries hospitalized from 2007 to 2017, CAHs submitted significantly fewer hospital diagnosis codes than non-CAHs, and short-term mortality rates adjusted for preexisting conditions but not in-hospital comorbidity measures were not significantly different by hospital type in most years. The findings suggest that short-term mortality outcomes at CAHs may not differ from those of non-CAHs after accounting for different coding practices for in-hospital comorbidities.

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