Speak Your Piece: Hospital Death Rates

[imgbelt img=pbs.jpg]A research report draws the wrong conclusion about the death rate at rural, critical access hospitals vs. the death rate at large, urban medical centers. The real story would have been if researchers had found no difference. 


The headline probably caught your attention: “Why Rural Hospitals May Pose a Greater Risk of Death.” The story was based on a study that found rural “critical access hospitals” had a slightly worse mortality rate than major medical centers. 

[imgcontainer left][img:pbs.jpg]“Greater risk of death” — PBS Newshour ran this headline on its posting of the story. The study found a risk gap of 1.8% between the nation’s largest, “medical Meccas” and small, rural hospitals designed to provide a basic level of care.

The researchers got the numbers right. But they gave the wrong reasons for the small difference in survival between rural, critical access hospitals and larger regional hospitals. 

Rural America has over 1,300 critical access hospitals. Such a hospital is mainly a medical hub for its community. It has an emergency room, several kinds of clinics, physical therapy and rehabilitation services. It has 25 beds or fewer but only four beds have acutely ill patients in them on a typical day. There may be a few more patients recuperating. Most such hospitals have no specialized facilities like intensive care. They don’t ordinarily keep patients with life-and-death illness.

Researchers at the Harvard School of Public Health, writing in the Journal of the American Medical Association, reported that between 2002 and 2010 a gap in survival developed between patients in these critical access hospitals and large medical centers. Specifically, death rates for people with heart attacks, pneumonia or heart failure in large, full-service hospitals have improved while survival chances have gotten a little worse in critical access hospitals. Patients with heart attack, pneumonia or heart failure are 1.8% more likely to die if they are hospitalized in a critical access hospital than in a large, full-service hospital. 

The Harvard researchers argued that the mortality rate of critical access hospitals was higher because these hospitals aren’t under the same pressure to improve as larger hospitals. Here is their logic: Medicare keeps statistics on deaths at large hospitals for patients being treated for heart attacks, pneumonia or heart failure. But Medicare doesn’t track these death statistics for critical access hospitals. Since they aren’t getting measured, the argument goes, critical access hospitals don’t perform as well.

But the Harvard group failed to understand how patients, families, critical access hospitals and regional medical centers interact.

Large urban hospitals, the “medical Meccas” have intensive care units and cardiac catheterization laboratories – highly specialized facilities that can be both lifesaving and terrifying. The noise, sleep deprivation and medication very commonly cause patients, particularly sick, old people, to lose their minds temporarily. It must be terrifying. Small, rural hospitals lack intensive care units and cardiac catheterization labs, but they have familiar surroundings and nearness to home and family. They are somewhat less likely to save your life and to make you temporarily crazy. Different people value these factors differently.

[imgcontainer][img:cah.png][source]Rural Assistance Center, HHS data

Map shows the location of critical access hospitals as of second quarter 2011. (Larger version.)

Medicare’s “standard of care” calls for a patient with a heart attack to get from the door of a hospital to the cardiac catheterization lab within 1.5 hours. If a person shows up at a critical access hospital emergency room with symptoms of a heart attack, the emphasis will be on making the diagnosis and arranging a speedy transfer to the regional medical center with its cardiac catheterization facilities. The patient with the developing heart attack probably won’t be admitted to the critical access hospital at all.

That patient will only be kept in the critical access hospital if he or she refuses to be sent to the medical center. This might be because they want to stay near home and family, even if they can’t have the high-tech intervention of the medical center. Perhaps they have already had all the cardiac intervention possible, or for some other personal reason have made the decision to stay in their home community.

The same pattern applies in cases of pneumonia, heart failure and all the other life-threatening catastrophes that happen to people. If recovery is likely with basic medical and nursing care in supportive surroundings, the small community hospital is the best and most economical place to be cared for. In a life-and-death situation, for a person who wants the best chance of survival if not comfort, the large, regional hospital is the best bet.