Characteristics of Patients Hospitalized in Rural and Urban ICUs From 2010 to 2019.

OBJECTIVES: Rural hospitals are threatened by workforce shortages and financial strain. To optimize regional critical care delivery, it is essential to understand what types of patients receive intensive care in rural and urban hospitals. DESIGN: A retrospective cohort study. SETTING AND PATIENTS: All fee-for-service Medicare beneficiaries in the United States who were 65 years old or older hospitalized in an ICU between 2010 and 2019 were included. Rural and urban hospitals were classified according to the 2013 National Center For Health Statistics Urban-Rural Classification Scheme for Counties. Patient comorbidities, primary diagnoses, organ dysfunction, and procedures were measured using the International Classification of Diseases, 9th and 10th revisions diagnosis and procedure codes. Standardized differences were used to compare rural and urban patient admission characteristics. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 12,224,097 ICU admissions between 2010 and 2019, and 1,488,347 admissions (12.2%) were to rural hospitals. The most common diagnoses in rural hospitals were cardiac (30.3%), infectious (24.6%), and respiratory (10.9%). Patients in rural ICUs had similar organ dysfunction compared with urban hospitals (mean organ failures in rural ICUs 0.5, sd 0.8; mean organ failures in urban ICUs 0.6, sd 0.9, absolute standardized mean difference 0.096). Organ dysfunction among rural ICU admissions increased over time (0.4 mean organ failures in 2010 to 0.7 in 2019, p < 0.001). CONCLUSIONS: Rural hospitals care for an increasingly complex critically ill patient population with similar organ dysfunction as urban hospitals. There is a pressing need to develop policies at federal and regional healthcare system levels to support the continued provision of high-quality ICU care within rural hospitals.

Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care.

Rationale: Intermediate care (also termed "step-down" or "moderate care") has been proposed as a lower cost alternative to care for patients who may not clearly benefit from intensive care unit admission. Intermediate care units may be appealing to hospitals in financial crisis, including those in rural areas. Outcomes of patients receiving intermediate care are not widely described. Objectives: To examine relationships among rurality, location of care, and mortality for mechanically ventilated patients. Methods: Medicare beneficiaries aged 65 years and older who received invasive mechanical ventilation between 2010 and 2019 were included. Multivariable logistic regression was used to estimate the association between admission to a rural or an urban hospital and 30-day mortality, with separate analyses for patients in general, intermediate, and intensive care. Models were adjusted for age, sex, area deprivation index, primary diagnosis, severity of illness, year, comorbidities, and hospital volume. Results: There were 2,752,492 hospitalizations for patients receiving mechanical ventilation from 2010 to 2019, and 193,745 patients (7.0%) were in rural hospitals. The proportion of patients in rural intermediate care increased from 4.1% in 2010 to 6.3% in 2019. Patient admissions to urban hospitals remained relatively stable. Patients in rural and urban intensive care units had similar adjusted 30-day mortality, at 46.7% (adjusted absolute risk difference -0.1% [95% confidence interval, -0.7% to 0.6%]; P = 0.88). However, adjusted 30-day mortality for patients in rural intermediate care was significantly higher (36.9%) than for patients in urban intermediate care (31.3%) (adjusted absolute risk difference 5.6% [95% confidence interval, 3.7% to 7.6%]; P < 0.001). Conclusions: Hospitalization in rural intermediate care was associated with increased mortality. There is a need to better understand how intermediate care is used across hospitals and to carefully evaluate the types of patients admitted to intermediate care units.

Availability of cancer care services and the organization of care delivery at critical access hospitals.

INTRODUCTION: Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas. METHODS: Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs. RESULTS: Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine. CONCLUSION: Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

Disparities in Geographic Access to Hospital Outpatient Pulmonary Rehabilitation Programs in the United States.

BACKGROUND: For individuals with COPD, pulmonary rehabilitation (PR) improves outcomes in terms of exercise capacity, severity of dyspnea, and health-related quality of life. However, many US patients with COPD do not use PR services. There has been limited research on geographic access to needed health-care services for individuals who live in rural communities in the United States. This study: (1) examines the geographic distribution of hospital-based outpatient PR programs in the US; and (2) compares the organizational characteristics of hospitals that offer PR programs and those that do not. METHODS: A multistep process supported the determination of whether a hospital provided PR services and included: program directory data from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) website and websites for AACVPR state affiliates and other COPD-relevant organizations; searches of hospital websites; e-mails with state contacts and other state organizations; and phone calls with hospital staff and state contacts. The study population included all Medicare-certified short-term acute care general medical and surgical hospitals. Data were collected and analyzed from January to November 2018. Medicare Provider of Service and American Hospital association data were used to compare the characteristics of hospitals with and without PR programs, using descriptive and bivariate statistics. RESULTS: 1,776 US counties do not have a hospital outpatient PR program located in a short-term acute care general medical or surgical hospital in the county, including 697 counties that do not have a hospital. The availability of a hospital outpatient PR program varies significantly by county type, hospital type and Census region. Hospitals located in a noncore county, designated as a Critical Access Hospital, or located in the South and the West were less likely to have an outpatient PR program. CONCLUSIONS: Significant geographic disparities exist in access to hospital outpatient PR. Potential strategies for addressing these disparities include: increasing clinician and patient awareness of the potential benefits of PR; offering staff training and incentives to supervise and provide PR services; improving Medicare reimbursement rates for PR services; replicating PR programs that have success serving rural areas; expanding cardiac rehabilitation programs to include PR; and assessing the use of telehealth technologies to provide PR in isolated areas.

Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?

OBJECTIVES: To quantify drive distances to hospital obstetric services and advanced neonatal care and to examine such disparities by residential rurality and insurance type. STUDY DESIGN: Data for all-payer maternal childbirth hospitalizations in 2002 (N = 661,240) and 2013 (N = 634,807) from nine geographically dispersed states were linked with the American Hospital Association annual surveys to identify maternal residence zip codes and the addresses of hospitals with obstetric services or advanced neonatal care. RESULTS: The uneven geographic distribution of hospital obstetric and advanced neonatal care increased between 2002 and 2013, varying by maternal residential rurality and insurance type. Women in rural non-core areas, with Medicaid or no insurance, and living in counties with lower income and educational attainment, had to travel farther to the nearest hospital with obstetric services or neonatal care than their counterparts. CONCLUSIONS: Women in communities that are already socioeconomically disadvantaged face increasing and substantial travel distances to access perinatal care.

Relationship between Hospital Policies for Labor Induction and Cesarean Delivery and Perinatal Care Quality among Rural U.S. Hospitals.

Many hospitals are adopting quality improvement strategies in obstetrics. This study characterized rural U.S. hospitals based on their hospital staffing and clinical management policies for labor induction and cesarean delivery, and assessed the relationship between policies and performance on maternity care quality. We surveyed all 306 rural maternity hospitals in nine states and used data from the Healthcare Cost and Utilization Project Statewide Inpatient Database hospital discharge database. We found staffing policies were more prevalent at lower-volume hospitals (92% vs. 86% for cesarean and 82% vs. 79%, both p < .01). Using multivariable logistic regression, we found hospitals with policies for cesarean delivery had up to 24% lower odds of low-risk cesarean (adjusted odds ratio = 0.76; 95% confidence interval=[0.67-0.86]) and non-indicated cesarean (0.78 [0.70-0.88]), with variability across birth volume. Clinical management and staffing policies are common, but not universal, among rural U.S. hospitals providing obstetric services and are generally positively associated with quality.

Why Are Obstetric Units in Rural Hospitals Closing Their Doors?

OBJECTIVES: To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods. DATA SOURCES: Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013-2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care. STUDY DESIGN: Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014. PRINCIPAL FINDINGS: Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care. CONCLUSIONS: Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care.

Location of childbirth for rural women: implications for maternal levels of care.

BACKGROUND: A recent American Congress of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (MFM) consensus statement on levels of maternity care lays out designations that correspond to specific capacities available in facilities that provide obstetric care. Pregnant women in rural and remote areas receive particular attention in discussions of regionalization and levels of care, owing to the challenges in assuring local access to high-acuity services when necessary. Currently, approximately half a million rural women give birth each year in US hospitals, and whether and which of these women give birth locally is crucial for successfully operationalizing maternal levels of care. OBJECTIVE: We sought to characterize rural women who give birth in nonlocal hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with nonlocal childbirth. STUDY DESIGN: This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in 9 states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a nonlocal hospital (at least 30 road miles from the patient's residence). We examined patient age, race/ethnicity, payer, rurality, clinical diagnoses (diabetes, hypertension, hemorrhage during pregnancy, placental abnormalities, malpresentation, multiple gestation, preterm delivery, prior cesarean delivery, and a composite of diagnoses that may require MFM consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation). RESULTS: The rate of nonlocal childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (adjusted odds ratio [AOR], 0.76; 95% confidence interval [CI], 0.68-0.86 for Medicaid vs private insurance) and by clinical conditions including multiple gestation (AOR, 1.82; 95% CI, 1.58-2.1), preterm deliveries (AOR, 2.41; 95% CI, 2.17-2.67), and conditions that may require MFM services or consultation (AOR, 1.28; 95% CI, 1.22-1.35). Rural women whose local hospital did not have a neonatal intensive or intermediate care unit had nearly double the odds of giving birth at a nonlocal hospital (AOR, 1.94; 95% CI, 1.64-2.31). CONCLUSION: Approximately 75% of rural women gave birth at local hospitals; rural women with preterm births and clinical complications, as well as those without local access to higher-acuity neonatal care, were more likely to give birth in nonlocal hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at nonlocal hospitals, implying a potential access challenge for this population.

The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities.

PURPOSE: The purpose of this study was to describe the types and combinations of clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by rural hospitals. METHODS: We conducted a telephone survey of 306 rural hospitals in 9 states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin, from November 2013 to March 2014 to assess their obstetric workforce. Bivariate associations between hospitals' annual birth volume and obstetric workforce characteristics were examined, as well as qualitative analysis of workforce changes and staffing challenges. FINDINGS: Hospitals with lower birth volume (<240 births per year) are more likely to have family physicians and general surgeons attending deliveries, while those with a higher birth volume more frequently have obstetricians and midwives attending deliveries. Reported staffing challenges include scheduling, training, census fluctuation, recruitment and retention, and intrahospital relationships. CONCLUSIONS: Individual hospitals working in isolation may struggle to address staffing challenges. Federal and state policy makers, regional collaboratives, and health care delivery systems can facilitate solutions through programs such as telehealth, simulation training, and interprofessional education.

Birth volume and the quality of obstetric care in rural hospitals.

BACKGROUND: Childbirth is the most common reason for hospitalization in the United States. Assessing obstetric care quality is critically important for patients, clinicians, and hospitals in rural areas. METHODS: The study used hospital discharge data from the Statewide Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, for 9 states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin) to identify all births in rural hospitals with 10 or more births/year in 2002 (N = 94,356) and 2010 (N = 103,880). Multivariate logistic regression was used to assess the relationship between hospital annual birth volume, measured as low (10-110), medium (111-240), medium-high (241-460) or high (>460), and 3 measures of obstetric care quality (low-risk cesarean rates for term, vertex, and singleton pregnancies with no prior cesarean; nonindicated cesarean; and nonindicated induction) and 2 patient safety measures (episiotomy and perineal laceration). RESULTS: The odds of low-risk and nonindicated cesarean were lower in medium-high and high-volume rural hospitals compared with low-volume hospitals after controlling for maternal demographic and clinical factors. In low-volume hospitals, odds of labor induction without medical indication were higher than in medium-volume hospitals, but not significantly different from medium-high or high-volume hospitals. Odds of episiotomy were greater in medium-high or high-volume hospitals than in low-volume hospitals. The likelihood of perineal laceration did not differ significantly by birth volume. CONCLUSIONS: Obstetric quality and safety outcomes vary significantly across rural hospitals by birth volume. Better performance is not consistently associated with either lower or higher volume facilities.

Rural Emergency Department staffing and participation in emergency certification and training programs.

CONTEXT: The practice of emergency medicine presents many challenges in rural areas. PURPOSE: We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to provide high-quality emergency care. METHODS: A national telephone survey of a random sample of rural hospitals with 100 or fewer beds was conducted in June to August 2006. Respondents included ED nurse managers and Directors of Nursing. A total of 408 hospitals responded (96% response rate). FINDINGS: A majority of rural hospitals use more than one type of staffing to cover the ED. The type of staffing varies by time period and ED volume. On weekdays, about onethird of hospitals use physicians on their own medical staff; one third use contracted coverage; 18% use both; and 14% use physician assistants and/or nurse practitioners with a physician on-call. Hospitals are more likely to use a combination of medical staff and contracted coverage on evenings and weekends. Advanced Cardiac Life Support training is common, but Pediatric Advanced Life Support, Advanced Trauma Life Support, and training in working as a team are less common. More registered nurses working in rural EDs have taken the Trauma Nursing Core Course than the Emergency Nursing Pediatric Course. CONCLUSIONS: Rural ED staff would benefit from additional continuing education opportunities, particularly in terms of specialized skills to care for pediatric emergency patients and trauma patients and training in working effectively in teams.

Pharmacist staffing, technology use, and implementation of medication safety practices in rural hospitals.

CONTEXT: Medication safety is clearly an important quality issue for rural hospitals. However, rural hospitals face special challenges implementing medication safety practices in terms of their staffing and financial and technical resources. PURPOSE: This study assessed the capacity of small rural hospitals to implement medication safety practices, with particular focus on pharmacist staffing and the availability of technology. METHODS: A telephone survey of a national random sample of small rural hospitals was conducted from March to May 2005 (N = 387 hospitals, 94.6% response rate). Survey respondents included pharmacists (89%) and directors of nursing (11%). Multivariate analyses examined the relationships between hospital organizational and financial variables and (1) the amount of pharmacist staffing; (2) use of pharmacy computers for medication safety activities; and (3) implementation of medication safety practices. FINDINGS: Many small rural hospitals have limited hours of on-site pharmacist coverage. Almost one quarter of hospitals either do not have a pharmacy computer or are not using it for clinical purposes. Half of the hospitals have implemented 4 key medication safety practices. Level of pharmacist staffing, use of technology, and implementation of medication safety practices are significantly related to hospital financial status and accreditation. CONCLUSIONS: Implementation of protocols related to medication use and key medication safety practices are areas where small rural hospitals could improve. The study results support a continuation of Medicare cost-based reimbursement policies to help ensure financial stability and support quality and patient safety activities in small rural hospitals.

Prioritizing patient safety interventions in small and rural hospitals.

BACKGROUND: A study was conducted in 2004 to determine if 26 interventions--distributed among nine patient safety areas and as recommended by an expert panel as relevant to rural hospitals--would be validated in terms of relevance and implementability for small and rural facilities. METHODS: The chief executive officers (CEOs) and/or key managers responsible for patient safety activities in a diverse group of 29 small and rural hospitals assessed the potential effectiveness and feasibility of the 26 interventions. Representatives of 25 hospitals participated in structured, follow-up phone discussions. RESULTS: Adverse drug events were the highest-priority area for 14 hospitals, followed by patient falls (selected by 5 hospitals). Some hospitals had already implemented intervention 1 (use at least two patient identifiers) and intervention 6 (read back of verbal orders) and thus ranked them highly, especially for implementability. Intervention 3 (24-hour pharmacist coverage) was ranked low, especially on implementability. Interventions involving health information technology were ranked lower by the hospitals than by the expert panel. DISCUSSION: Safety interventions should reflect the general state of the science of safe practices while incorporating relevant contextual issues unique to rural hospitals. The results have important implications for survey and accreditation activity, and the focus of technical assistance and research efforts.

Providing hospice care in rural areas: challenges and strategies.

Hospices in rural settings face challenges in the provision of hospice care as a result of their location and the size of their service area population. To ascertain the challenges that hospices face in serving rural communities, researchers conducted in-depth case studies of four different models of hospice care in rural areas. The authors describe strategies used by the case study hospices and recommend policies that could increase access to hospice care for rural Medicare beneficiaries and other rural residents. National initiatives to improve end-of-life care need to consider the special challenges faced by rural hospices.

Do rural elders have limited access to Medicare hospice services?

OBJECTIVES: To examine whether there are urban-rural differences in use of the Medicare hospice benefit before death and whether those differences suggest that there is a problem with access to hospice care for rural Medicare beneficiaries. DESIGN: Observational study using 100% of Medicare enrollment, hospice, and hospital claims data. SETTING: Inpatient hospitals and hospices. PARTICIPANTS: Persons aged 65 and older in the Medicare program who died in 1999. MEASUREMENTS: Rates of hospice use before death and in-hospital death rates were calculated. RESULTS: In 1999, there were 1.76 million deaths of Medicare beneficiaries aged 65 and older. Hospice services were used by 365,700 of these beneficiaries. Rates of hospice care before death were negatively associated with degree of rurality. The lowest rate of hospice use, 15.2% of deaths, was seen in rural areas not adjacent to an urban area. The highest rate of use, 22.2% of deaths, was seen in urban areas. Rural areas adjacent to urban areas had an intermediate level of hospice use (17.0% of deaths). Hospices based in rural areas had a smaller number of elderly patients each year than hospices based in urban areas (P<.001) and were more likely to have very low volumes (average daily census of three patients or less). CONCLUSION: The consistently lower use of Medicare hospice services before death and smaller sizes of rural hospices suggest that the combination of Medicare hospice payment policies and hospice volumes are problematic for rural hospices. Adjusting Medicare payment policies might be a critical step to assure availability of hospice services forterminally ill beneficiaries regardless of where they live.

Understanding rural hospital bypass behavior.

CONTEXT: Though many rural hospitals offer a broad array of services, local residents may choose more distant facilities for inpatient care services. Depending on the extent of the bypass phenomenon, hospitals may experience financial distress, reduced service offerings, or closure. PURPOSE: This study provides a descriptive analysis of rural hospital bypass behavior in 7 states. METHODS: We examine hospital discharge data for calendar years 1991 and 1996 to determine the extent to which patients admitted from rural areas are bypassing local facilities. We also assess whether there are trends in bypass patterns over time. Our primary specification of bypass is defined as a discharge from a hospital between 15 and 1000 miles from the closest facility. FINDINGS: We found an overall bypass rate of 30%. This overall rate changed little between 1991 and 1996. Subgroups of patients, defined by payer and diagnosis, had differing propensities to bypass local rural facilities. Patients with managed care or commercial insurance had higher bypass rates compared to patients who relied on other payer sources. Medicare and uninsured (self-pay) patients had lower bypass rates. Payer type differences persisted when cases were divided into emergent and scheduled categories. Patients seeking general medical or obstetrical care had lower bypass rates than patients discharged with a diagnosis related group (DRG) related to complex medical, general surgery, or specialty surgery services. With the exception of normal delivery, DRG codes frequently associated with bypass discharges involved procedures or surgery that may not be offered by smaller rural facilities. CONCLUSIONS: Our results indicate that rural patients, or their admitting physicians, perceive local rural hospitals as a viable option for many inpatient care services but prefer other facilities for treatments beyond the scope of general medical or surgical treatment.