• Adam J Gadzinski, Justin B Dimick, Zaojun Ye, John L Zeller, and David C Miller.
• Department of Urology, University of Michigan Health System, Ann Arbor.
• JAMA Surg. 2014 Jul 1;149(7):671-7.

ImportanceThere is growing interest in the use of health care resources by critical access hospitals (CAHs), key providers of medical care for many rural populations.ObjectiveTo evaluate discharge practice patterns and use of post-acute care after surgical admissions at CAHs.Design, Setting, And ParticipantsWe used data from the Nationwide Inpatient Sample (2005-2009) and American Hospital Association to perform a retrospective cohort study of patients undergoing common inpatient surgical procedures at CAHs or non-CAHs.ExposuresThe CAH status of the admitting hospital.Main Outcomes And MeasuresHospital transfer, discharge with post-acute care, or routine discharge.ResultsAmong the 1283 CAHs and 3612 non-CAHs included in the American Hospital Association annual survey, 34.8% and 36.4%, respectively, reported data to the Nationwide Inpatient Sample. For each of 6 common inpatient surgical procedures, a greater proportion of patients from CAHs were transferred to another hospital (P < .01); however, patients discharged from CAHs were less likely to receive post-acute care for all but 1 of the procedures examined (P < .01, except transurethral resection of prostate, P = .76). After adjustment for patient and hospital factors, the higher likelihood of transfer by CAHs vs non-CAHs persisted for 3 procedures: hip replacement (odds ratio, 1.90; 95% CI, 1.01-3.57), colorectal cancer resection (3.37; 2.23-5.09), and cholecystectomy (1.67; 1.27-2.19) (P < .05 for each), but differences in the use of post-acute care did not. In subset analyses, Medicare beneficiaries treated in CAHs were less likely to be discharged with post-acute care after hip fracture repair (odds ratio, 0.65; 95% CI, 0.47-0.89) and hip replacement (0.70; 95% CI, 0.51-0.96).Conclusions And RelevanceHospital transfers occur more often after surgical admissions at CAHs. However, the proportion of patients at CAHs using post-acute care is equal to or lower than that of patients treated in non-CAHs. These results will affect the ongoing debate concerning CAH payment policy and its implications for health care delivery in rural communities.

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