Patient Bypass Behavior and Critical Access Hospitals: Implications for Patient Retention

PURPOSE: To assess the extent of bypass for inpatient care among patients living in Critical Access Hospital (CAH) service areas, and to determine factors associated with bypass, the reasons for bypass, and what CAHs can do to retain patients locally. METHODS: Six hundred and forty-seven subjects, aged 18 years and older, who had been admitted to a hospital for inpatient care in the past 12 months and lived within 15-20 miles of 25 randomly selected CAHs were surveyed by phone during the period from early February through late July 2005. Survey questions included demographic characteristics, general health status, travel time/distance to health care, questions on satisfaction with local health services, bypass behavior, and solicited suggestions on how local hospitals could retain patients locally. FINDINGS: About 60% of surveyed patients bypassed their local CAHs for inpatient care including 16% who were referred to another facility by the local CAH/health care providers and would use the local hospital if needed services were available. Bypass rates ranged from 16% to 70% across the sampled CAHs. Factors associated with bypass included age, income, satisfaction with the local hospital, and traveling distance/time. Lack of specialty care, limited services, and the quality/reputation of local services/doctors were most frequently mentioned as reasons why patients bypass local CAHs. CONCLUSIONS: The bypass rate for sampled CAHs is considerably higher than the 20%-50% bypass rates documented in the literature for all hospitals in general using discharge/administrative data. The sizeable variation in bypass rates across CAHs suggests that the appropriate response/fix should come from the facility/community levels.     

State Legislation and Policy Affecting Rural Hospital Conversion and Closure

Many rural hospitals have closed or converted to organizations that provide health services other than general, acute inpatient care. However, little is known about why rural hospitals convert rather than close. This study evaluates the relationship between state policy and rates of rural hospital conversion relative to rates of rural hospital closure. The expectation was that the relationship among state policies and rates of conversion and rates of closure differs as a function of whether a state policy facilitates rural hospital transition to alternative models of care or supports them in their existing form. National data were analyzed for all rural hospitals from 1984 to 1991. Results indicate that state policies have done little to facilitate widespread adoption of conversion among rural hospitals. Despite these findings, results also indicate that some state policies have resulted in an increase in the rate of rural hospitals conversions as an alternative to closure.     

Utilization of hospital services by the elderly: geriatric crisis in one Canadian single payer system.

As the number and proportion of elderly persons in the Canadian population increase, utilization of health services by the elderly becomes a growing concern for health service insurers, financial managers and policy makers, as well as for care providers. The purpose of this paper is to present the results of a study to analyse the use of hospital services by the elderly in Alberta since the introduction of a universal single payer health care insurance system in 1970. The study period coincides with the implementation of publicly-financed comprehensive medical and hospital insurance programmes for all Alberta residents, making it possible to perform historical and population-based utilization analyses. Thus the data used for the study included all hospital discharge abstracts generated by all Alberta hospitals from 1971 to 1991. Trends in hospital service utilization by the elderly in terms of total number of separations, patient-days, and per case measures such as average length of stay as well as per capita utilization rates were reviewed to identify utilization patterns over the study period. Further, relative per capita utilization measures, in comparison with the base year (1971), age group 15-44, male, metropolitan residents, were derived and historical trends identified. A series of regression analyses were carried out to estimate the effects of age, sex and origin on utilization rates. In addition, for the period of 1984-1991, Diagnosis Related Groups (DRG) case weights were used to measure per capita and per case rates and to analyse historical relative utilization rates over the 8-year period. In general, there has been a significant decline in hospital utilization by Albertans under the publicly-financed single payer system, but utilization rates for elderly have remained high, resulting in high relative utilization rates in comparison with other age groups. It was also noted that per capita utilization rates for rural residents were substantially higher than urban residents. It appears that these higher utilization rates by the elderly and rural residents in combination with tight bed and financial control by the government have been causing significant bed shortage problems for non-elderly elective patients in urban areas.     

Access to care in rural America: impact of hospital closures

This article employs a quasi-experimental, pre/post comparison group design to determine whether rural hospital closures (n = 11) have had a detrimental impact on access to inpatient and outpatient care for the Medicare population. Closure areas experienced a significant decrease in medical admissions, although admission rates remained higher than in comparison areas. Physician services were not found to substitute for inpatient services following a closure. No adverse impacts on mortality were observed. Patients in closure areas were more likely to be admitted to urban teaching hospitals following the closure of their local hospital.     

Swing Beds and Rural Hospitals in New York, 1991 to 1994

Abstract: New York implemented a hospital swing bed program in 1991 to allow rural hospitals access to Medicare Part B financing, increase utilization of hospital rehabilitation services, and facilitate the care of patients in their home communities. Between the years 1991 and 1994, 13 hospitals participated in the program. The authors used the New York State Department of Health annual hospital reporting data to examine the hospital swing bed experience for length of stay, payer type, and discharge disposition. Eighty-six percent of swing bed admissions came from the acute care units of the host hospital or a referral hospital. The average length of stay decreased from 25 days to 19 days during the study period with almost one-half of the patients being discharged. Swing bed revenues accounted for 3.4 percent of the total hospital gross revenues by 1994. Respite care, a component unique to New York, accounted for an increasing percent of admissions throughout the study period. The program served a useful rehabilitative function, and it represents one strategy to care for rural patients near their homes.     

Patterns of travel for rural individuals hospitalized in New York State: relationships between distance, destination, and case mix.

The travel patterns of individuals living in rural areas of New York State who were discharged from short-term general hospitals in New York State in 1983 are examined. Counties are used as the geographical unit, and rural individuals who cross geographic boundaries to obtain inpatient hospital care are compared with those who receive such care in their own geographic area. Hospital serving the rural population of New York are classified into three types: urban, consisting of all hospitals located in MSAs; rural referral centers; and other rural hospitals. Next, the rural patients who are admitted to each of these three types of hospitals are characterized in terms of distance traveled, case mix, length of stay, and age. Individuals who travel beyond the counties adjacent to their county of residence had a higher case mix index but were less likely to be more than 75 years old. Distance traveled and the expected cost of care were strongly positively related for patients admitted to urban and rural referral center hospitals, but were only weakly related for other rural hospitals. Finally, comparisons of rural patients in these three types of hospitals were performed adjusting for DRG mix, a comparison which is relevant to hospital reimbursements under the Medicare Prospective Payment System. Using several measures of illness severity, rural patients in urban hospitals and rural referral center hospitals were more severely ill than rural patients in other rural hospitals after adjusting for DRG mix. We conclude that somewhat higher payments to urban hospitals and rural referral center hospitals in New York are justified based on the more severely ill patients which they treat     

Bypassing the Local Rural Hospital for Outpatient Procedures

ABSTRACT:  Purpose: To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures. Methods: We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004. Findings: Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patient's medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care. Conclusions: The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations .     

Market Shares for Rural Inpatient Surgical Services: Where Does the Buck Stop?

Utilization of surgical services by rural citizens is poorly understood, and few data are available about rural hospitals' surgical market shares and their financial implications. Understanding these issues is particularly important in an era of financially stressed rural hospitals. In this study information about rural surgical providers and services was obtained through telephone interviews with administrators at Washington state's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data were used to measure market shares and billed charges for rural surgical services. ZIP codes were used to assign rural residents to a hospital service area (HSA) of the nearest hospital, providing the geographic basis for market share calculations. "Total hospital expenses" from the American Hospital Association Guide were used as a proxy for hospital budget, and the surgical financial contribution was expressed as a ratio of billed surgical charges to total hospital expense. For rural hospitals as a whole, 21 percent of admissions and 43 percent of billed inpatient charges resulted from surgical services. In 1989, 27,202 rural Washington residents were hospitalized for surgery. Overall, 42 percent went to the closest rural hospital, 14 percent went to other rural hospitals, and 44 percent went to urban hospitals. The presence of surgical providers markedly increased local market shares, but a substantial proportion of basic surgical procedures bypassed available local services in favor of urban hospitals. For example, about one-third of patients needing cholecystectomies, a basic general surgery of low complexity, bypassed local hospitals with staff surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)     

Risk-adjusted In-hospital Death Rates for Peer Hospitals in Rural and Urban Regions

Abstract: The purpose of this research project was to compare inpatient mortality rates for rural hospitals with mortality rates of urban hospitals of given sizes and ranges of service. Statistical adjustments for risk were made in the probability of death during hospitalization for 43,000 patients across 166 hospitals by age, gender, principal diagnosis, principal surgical procedure, characteristics of the secondary diagnoses, and whether or not cancer was a seconday diagnosis. Eighty-three small hospitals that had a relatively unspecialized range of services constituted the study group. Patient characteristics of this study group were moderately representative of the national population. A standardized score was calculated for each hospital using a formula based on the actual hospital death rate and the death rate expected for a given hospital with patients of the same demographic and medical characteristics. Patients admitted to hospitals in nonmetropolitan areas had a mortality rate of 0.41 percent compared with a mortality rate of 0.66 percent in peer hospitals in metropolitan areas. After mortality rates were risk-adjusted and converted to z scores, nonmetropolitan areas had an average z of +0.16, and metropolitan areas had an average z of -0.25, where positive z scores reflect a lower-than-average adjusted mortality rate. The metropolitan-nonmetropolitan (urban-rural) difference was not statistically significant, but it is meaningful in that rural hospitals tended to have a lower adjusted mortality rate than urban hospitals of the same size and type, indicating that rural hospitals had the same or lower adjusted mortality rates. The possibility of urban hospitals having riskier patients was minimized but could not be definitively ruled out. Taken together with other studies, the data are consistent with the view that small rural hospitals generally make appropriate transfer decisions for severely ill patients and provide quality care for retained patients .     

Assessing providers of coronary revascularization: a method for peer review organizations.

OBJECTIVES. Current methods to evaluate quality of care are usually limited to reviews of individual cases or comparisons of hospital mortality rates. We present an alternative method that compares complication rates adjusted for patient characteristics. METHODS. Detailed clinical data that were specifically designed for quality comparisons of providers of revascularization procedures were abstracted from the medical records of 1998 Medicare patients, in 16 hospitals, who had coronary artery bypass surgery and 2091 patients, in 16 hospitals, who had angioplasty. Providers were ranked on the basis of an unadjusted risk, a risk adjusted for detailed clinical information, and a risk adjusted only for patient comorbidities. RESULTS. Complication rates differed significantly and substantially among the hospitals. Clinical adjustment changed the hospital rankings for the bypass surgery hospitals, but not for the angioplasty hospitals. Adjustment for comorbidities did not affect hospital rankings for either procedure. CONCLUSIONS. When sample sizes are limited, adverse outcome rates may be a more sensitive measure of quality of care than mortality rates. Rates that are unadjusted or adjusted only for comorbidities may be inadequate for evaluating some providers of bypass surgery.     

Multifaceted Inpatient Psychiatry Approach to Reducing Readmissions: A Pilot Study

ABSTRACT:  Context: Access to psychiatric services, particularly inpatient psychiatric care, is limited and lacks comprehensiveness in rural areas. Purpose: The purpose of this study was to evaluate the impact on readmission rates of a multifaceted inpatient psychiatry approach (MIPA) offered in a rural hospital. Methods: Readmissions within 30 days of patients who were admitted to an inpatient psychiatric unit using a MIPA model of care (N = 147) were compared to readmissions of a comparison group of patients who were admitted prior to the adoption of the MIPA (N = 37). Case mix differences were adjusted using multiple logistic regression analysis (N = 184). Findings: Patients treated in the MIPA model of care had lower odds of readmission within 30 days (odds ratio 0.14, 95% CI 0.02-0.87, P < .03). Conclusions: Effective inpatient psychiatric care can be provided in rural hospitals.     

Variations in clinical decisions: a study of orthopaedic patients.

Three groups of patients were clinically reviewed within a new orthopaedics department: patients who were on an inpatient waiting list for surgery; new referrals from general practitioners; and patients who had been referred earlier and were awaiting an appointment for outpatient consultation. Approximately two-fifths of patients who were already on the inpatient waiting list, and who had confirmed their wish to remain on it, were considered on clinical review not to require inpatient treatment. A third of patients attending for first outpatient consultations were immediately returned to the continuing care of their general practitioner and this proportion was higher (47%) amongst patients who were waiting for outpatient appointments and who had not been referred to a named hospital consultant. These findings draw attention to the possible inappropriate use of specialist hospital facilities because of clinical decisions taken by some general practitioners and also to variations in the threshold for surgical intervention used by hospital consultants. It is important that the medical profession develops a consensus approach to the clinical management of patients with common conditions. It is also important that clinical review of patients on inpatient waiting lists, especially those who have been waiting a long time, becomes a routine part of waiting list management. Under the new British health care system, it is likely that purchasers of health care will seek to ensure that these issues are being dealt with by hospitals with which they are considering placing contracts.     

Intensive Care Unit Utilization and Interhospital Transfers As Potential Indicators of Rural Hospital Quality

CONTEXT: Obtaining meaningful information from statistically valid and reliable measures of the quality of care for disease-specific care provided in small rural hospitals is limited by small numbers of cases and different definitive care capacities. An alternative approach may be to aggregate and analyze patient services that reflect more generalized care processes. PURPOSE: To evaluate the applicability of intensive care unit (ICU) utilization and interhospital transfers as potential indicators of quality in rural hospitals. METHODS: Secondary data analysis of ICU utilization and interhospital transfer practices in Iowa's Critical Access (CAH), rural, rural referral, and urban hospitals. FINDINGS: Rural hospitals have fewer resources, provide a more limited range of definitive care services, and rely to a greater extent on transferring patients to other hospitals capable of providing the required definitive care. Examining ICU utilization and interhospital transfer patterns we found (1) that lower percentages of patients receive ICU care in smaller facilities; (2) higher transfer rates for both ICU and non-ICU patients in CAH hospitals; (3) shorter average lengths of stay for ICU patients from smaller hospitals who were transferred; and (4) lower mortality rates for CAH and rural hospital ICU patients. CONCLUSIONS: Examining ICU utilization and interhospital transfer patterns offers potential insights into rural hospital quality measurement and comparisons.     

Rural Radiology: Who is Producing Images and Who is Reading Them?

The purpose of this study is to identify the local availability and trends in local availability of imaging technology and interpretation services in rural hospitals in the northwestern United States during the period between 1991 to 1994. Another objective is to describe hospital and community factors associated with the diffusion of image production and interpretation services. The information for this study was gathered through telephone surveys of rural hospital administrators in eight northwestern states in 1991 and 1994. The availability of magnetic resonance imaging (MRI) equipment, computed tomography (CT) scanners, ultrasonography equipment, and dedicated mammography equipment increased between 1991 and 1994. The increases in MRI units were primarily in mobile equipment, while ultrasonography and mammography equipment increases were primarily fixed hospital-based units. In 1994, image interpretation in the rural hospitals was provided by both primary care and radiology physicians. Forty-six (11.5%) of the rural hospitals had no on-site radiology services and only 73 (18%) had daily radiology services. Between 1991 and 1994, 12 hospitals gained at least once-a-week radiology services, but 24 lost all radiology services. Teleradiology availability more than doubled during the three years. Radiology technology has diffused widely into rural communities in this region of the United States at differing rates for large and small hospitals. Radiologists are available to these hospitals only 46 percent of the days each year, with more days of availability in the larger hospitals and fewer days in the smaller hospitals. Teleradiology capability is increasing more rapidly in the larger hospitals that have radiologists more readily available.     

Access implications of rural hospital closures and conversions

This article examines the effects of rural hospital closures and conversions on various structural dimensions of access. Based on a data set of rural hospitals in Texas during the period 1985-1990, the results indicate that closure or conversion typically had relatively little detrimental effect on hospital services and distance to alternative sources of care, but hospital bed and physician availability may have been adversely affected in certain cases. Rural hospital conversions to alternative types of health care facilities, such as ambulatory care clinics, do appear to have maintained the availability of a restricted set of medical services in some rural areas.     

Rural Hospital Inpatient Surgical Volume: Cutting-edge Service or Operating on the Margin?

Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services--and these are considerable--but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens.     

Outpatient mastectomy: clinical, payer, and geographic influences

OBJECTIVE: To determine (1) the use of outpatient services for all surgical breast procedures for breast cancer and (2) the influence of payer and state on the use of outpatient services for complete mastectomy in light of state and federal length-of-stay managed care legislation. DATA SOURCES: Healthcare Cost and Utilization Project representing all discharges from hospitals and ambulatory surgery centers for five states (Colorado, Connecticut, Maryland, New Jersey, and New York) and seven years (1990-96). STUDY DESIGN: Longitudinal, cross-sectional analyses of all women undergoing inpatient and outpatient complete mastectomy (CMAS), subtotal mastectomy (STMAS), and lumpectomy (LUMP) for cancer were employed. Total age-adjusted rates and percentage of outpatient CMAS, STMAS, and LUMP were compared. Independent influence of state and HMO payer on likelihood of receiving an outpatient CMAS was determined from multivariate models, adjusting for clinical characteristics (age < 50 years, comorbidity, metastases, simple mastectomy, breast reconstruction) and hospital characteristics (teaching, ownership, urban). PRINCIPAL FINDINGS: In 1993, 1 to 2 percent of CMASs were outpatient in all states. By 1996, 8 percent of CMASs were outpatient in Connecticut, 13 percent were outpatient in Maryland, and 22 percent were outpatient in Colorado. In comparison, LUMPs were 78 to 88 percent outpatient, and by 1996, 43 to 72 percent of STMASs were outpatient. In 1996, women were 30 percent more likely to receive an outpatient CMAS in New York, 2.5 times more likely in Connecticut, 4.7 times more likely in Maryland, and 8.6 times more likely in Colorado compared to New Jersey. In addition, women with Medicare, Medicaid, or private commercial insurance were less likely to receive an outpatient CMAS compared to women with an HMO payer. CONCLUSIONS: LUMP is an outpatient procedure, and STMAS is becoming primarily outpatient. CMAS, while still primarily inpatient, is increasingly outpatient in some states. Although clinical characteristics remain important, the state in which a woman receives care and whether she has an HMO payer are strong determinants of whether she receives an outpatient CMAS.     

Orthopedic surgery in rural American hospitals: a survey of rural hospital administrators

Rural American residents prefer to receive their medical care locally. Lack of specific medical services in the local community necessitates travel to a larger center which is less favorable. This study was done to identify how rural hospitals choose to provide orthopedic surgical services to their communities. Methods: All hospitals in 5 states located in communities that met the criteria for a rural town according to the Rural Urban Commuting Area codes were included. A survey with topics including community and hospital demographics, orthopedic surgical workforce and demand, surgical services, and the perceived benefit of orthopedic services was sent to the hospital administrators. Results: Of the 223 rural hospitals surveyed, 145 completed the survey. Of those completing the survey, 30% had at least one full‐time orthopedic surgeon, 25% did not provide any orthopedic surgical services, 65% never had an orthopedic surgeon on ER call, 33% were recruiting an orthopedic surgeon, 52% stated that it is more difficult to recruit an orthopedic surgeon vs a general surgeon, and 71% of the administrators acknowledged a need for additional orthopedic surgical services in their community. For those hospitals that did not have a full‐time orthopedic surgeon, members of those communities traveled a mean distance of 55 miles for emergency orthopedic surgical care as reported by the hospital administrators. Conclusions: There are many rural communities that have limited access to orthopedic surgical services. While many of the rural hospital administrators feel that there is a need for additional orthopedic surgical services in their communities, it is difficult to recruit orthopedic surgeons to these areas.     

Is There a Role for the Small Rural Hospital?*

Rural hospitals represent almost half of all short-stay nonfederal general hospitals in the United States, but have been more severely affected than their urban counterparts by changes in reimbursement, regulation, and technology. Two hundred and six rural community hospitals closed during the first nine years of the 1980s, and the rate of closure is accelerating. Using secondary data sources to examine the structure, role, and content of rural hospitals, small rural hospitals are described and compared to larger and nonrural hospitals. Rural hospitals differ systematically from other hospitals in the United States, with smaller daily censuses, lower occupation rates, shorter lengths of stay, and disproportionately high shares of Medicare patients. They are dominated by very small institutions, with more than 1,000 rural hospitals having fewer than 50 beds. Small rural hospitals offer a core of basic services to the populations they serve. Emergency, obstetric, and newborn services are virtually ubiquitous in rural hospitals of all sizes, and they are also more likely to offer long-term nursing and home care services than urban hospitals of similar size. The inpatient diagnostic and procedural mix of these institutions demonstrates that they provide care for common medical and surgical conditions of low complexity. Rural hospitals are also relatively inexpensive, representing only 6 percent of total expenditures for hospital care. Given their central role in supporting the provision of health services to rural areas, the apparent appropriateness of the conditions they treat, and their relatively modest cost, it would seem reasonable to use federal policy to stabilize our previous investment in these institutions.