• Karen E Joynt, E John Orav, and Ashish K Jha.
• Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA. kjoynt@partners.org
• JAMA. 2013 Apr 3;309(13):1379-87.

ImportanceCritical access hospitals (CAHs) provide inpatient care to Americans living in rural communities. These hospitals are at high risk of falling behind with respect to quality improvement, owing to their limited resources and vulnerable patient populations. How they have fared on patient outcomes during the past decade is unknown.ObjectiveTo evaluate trends in mortality for patients receiving care at CAHs and compare these trends with those for patients receiving care at non-CAHs.Design, Setting, And PatientsRetrospective observational study using data from Medicare fee-for-service patients admitted to US acute care hospitals with acute myocardial infarction (1,902,586 admissions), congestive heart failure (4,488,269 admissions), and pneumonia (3,891,074 admissions) between 2002 and 2010.Main Outcome MeasuresTrends in risk-adjusted 30-day mortality rates for CAHs and other acute care US hospitals.ResultsAccounting for differences in patient, hospital, and community characteristics, CAHs had mortality rates comparable with those of non-CAHs in 2002 (composite mortality across all 3 conditions, 12.8% vs 13.0%; difference, -0.3% [95% CI, -0.7% to 0.2%]; P = .25). Between 2002 and 2010, mortality rates increased 0.1% per year in CAHs but decreased 0.2% per year in non-CAHs, for an annual difference in change of 0.3% (95% CI, 0.2% to 0.3%; P < .001). Thus, by 2010, CAHs had higher mortality rates compared with non-CAHs (13.3% vs 11.4%; difference, 1.8% [95% CI, 1.4% to 2.2%]; P < .001). The patterns were similar when each individual condition was examined separately. Comparing CAHs with other small, rural hospitals, similar patterns were found.Conclusions And RelevanceAmong Medicare beneficiaries with acute myocardial infarction, congestive heart failure, or pneumonia, 30-day mortality rates for those admitted to CAHs, compared with those admitted to other acute care hospitals, increased from 2002 to 2010. New efforts may be needed to help CAHs improve.

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