Defining rural teaching hospitals in Canada: Developing and testing a new definition.

INTRODUCTION: The current definition of 'teaching hospital' provided by Canadian Institute of Health Information (CIHI) focuses on large academic teaching hospitals. High-quality rural training experiences have been identified as a key component of training the future rural medical workforce. Identifying communities and hospitals where this training is currently available and taking place is important in understanding the current landscape of available rural training but is hampered by the lack of an agreed upon definition of 'rural teaching hospital'. This limits the understanding of current rural training landscapes, comparison across regions and research in this area. We propose a definition of a 'rural teaching hospital'. METHODS: Using the CIHI definition of rural as an initial reference point, we used accessible data from the University of Calgary and University of Alberta Distributed Medical Education (DME) programs to develop a definition of a 'rural teaching hospital'. We then identified rural Alberta hospitals to show how this definition would work in practice. RESULTS: Our definition of a rural teaching hospital is a hospital situated in a town of <30,000 people, teaching occurs at least 36 h a week and that teaching includes at least Family Medicine clerkship OR Family Medicine residency rotations. We identified 104 Alberta rural hospitals. The University of Calgary and University of Alberta DME programs included 70 communities and 44 of these communities met all three proposed criteria for rural teaching hospitals. CONCLUSION: Creating a working definition of a 'rural teaching hospital' is of high importance for both research and for day-to-day operations of rural educational units.

Résumé Introduction: La définition du terme "hôpital d'enseignement " selon l'Institut canadien d'information sur la santé (ICIS) désigne surtout les grands hôpitaux universitaires. L'expérience de formation de bonne qualité en milieu rural est un élément essentiel de la formation du futur personnel médical en milieu rural. Il importe de déterminer quels sont les communautés et les hôpitaux où cette formation a lieu pour comprendre le contexte actuel de la formation rurale offerte, mais l'on se bute à une définition du terme " hôpital d'enseignement rural " qui ne fait pas consensus. Cela limite la compréhension des contextes actuels de formation en milieu rural, la comparaison entre régions et la recherche sur cette question. Nous proposons donc une définition du terme " hôpital d'enseignement rural ". Méthodologie: Avec la définition de l'ICIS de l'adjectif rural comme point de départ, nous avons utilisé les données accessibles des programmes d'éducation médicale satellite de l'Université de Calgary et de l'Université de l'Alberta pour formuler une définition du terme " hôpital d'enseignement rural ". Nous avons ensuite identifié les hôpitaux de l'Alberta pour illustrer comment la définition s'insère dans la pratique. Résultats: Selon nous, un hôpital d'enseignement rural désigne un hôpital situé dans une ville de < 30 000 personnes, l'enseignement y a lieu pendant au moins 36 h par semaine et il inclut au moins un stage en médecine familiale OU des rotations de résidence en médecine familiale. Au total, 104 hôpitaux ruraux de l'Alberta répondaient à cette définition. Les programmes d'éducation médicale satellite de l'Université de Calgary et de l'Université de l'Alberta comptaient 70 communautés et 44 d'entre elles remplissaient les trois critères proposés pour être reconnues avoir un hôpital d'enseignement rural. Conclusion: Il est très important de formuler une définition de travail du terme " hôpital d'enseignement rural " tant pour la recherche que pour les activités quotidiennes des unités d'éducation en milieu rural. Mots-clés: Définitions, éducation médicale satellite, éducation médicale, hôpitaux ruraux.

Characteristics of US Rural Hospitals by Obstetric Service Availability, 2017.

Objectives. To describe characteristics of rural hospitals in the United States by whether they provide labor and delivery (obstetric) care for pregnant patients.Methods. We used the 2017 American Hospital Association Annual Survey to identify rural hospitals and describe their characteristics based on the lack or provision of obstetric services.Results. Among the 2019 rural hospitals in the United States, 51% (n = 1032) of rural hospitals did not provide obstetric care. These hospitals were more often located in rural noncore counties (counties with no town of more than 10 000 residents). Rural hospitals without obstetrics also had lower average daily censuses, were more likely to be government owned or for profit compared with nonprofit ownership, and were more likely to not have an emergency department compared with hospitals providing obstetric care (P for all comparisons < .001).Conclusions. Rural US hospitals that do not provide obstetric care are located in more sparsely populated rural locations and are smaller than hospitals providing obstetric care.Public Health Implications. Understanding the characteristics of rural hospitals by lack or provision of obstetric services is important to clinical and policy efforts to ensure safe maternity care for rural residents.

Rural Level III centers in an inclusive trauma system reduce the need for interfacility transfer.

BACKGROUND: Development of Level III trauma centers in a regionalized system facilitates early stabilization and prompt transfer to a higher level center. The resources to care for patients at Level III centers could also reduce the burden of interfacility transfers. We hypothesized that the development and designation of Level III centers in an inclusive trauma system resulted in lower rates of transfer, with no increase in morbidity or mortality among the non-transferred patients. METHODS: State trauma registry data from January 2009 through September 2015 were examined from five rural hospitals that transfer patients to our highest (Level II) trauma center and resource hospital. These five rural hospitals began receiving state support in 2010 to develop their trauma programs and were subsequently verified and designated Level III centers (three in 2011, two in 2013). Multivariate logistic regression was used to examine the adjusted odds of patient transfers and adverse outcomes, while controlling for age, gender, penetrating mechanism, presence of a traumatic brain injury, arrival by ambulance, and category of Injury Severity Score. The study period was divided into "Before" Level III center designation (2009-2010) and "After" (2011-2015). RESULTS: 7,481 patient records were reviewed. There was a decrease in the proportion of patients who were transferred After (1,281/5,737) compared to Before (516/1,744) periods (22% vs. 30%, respectively). After controlling for the various covariates, the odds of patient transfer were reduced by 32% (p < 0.0001) during the After period. Among non-transferred patients, there were no significant increases in adjusted odds of mortality, or hospitalizations of seven days or more, Before versus After. CONCLUSIONS: Development of rural Level III trauma centers in a regionalized system can significantly reduce the need for transfer to a remote, higher level trauma center. This may benefit the patient, family, and trauma system, with no adverse effect upon patient outcome. LEVEL OF EVIDENCE: Epidemiological, level III.

The Impact of Hospital Characteristics on the Availability of Radiology Services at Critical Access Hospitals.

PURPOSE: Although all critical access hospitals (CAHs) provide basic medical and radiographic imaging services, it remains unclear how CAHs provide additional imaging services given relatively low patient volumes and high resource costs. The aim of this study was to examine whether CAHs with more resources or access to resources through affiliation with larger systems are more likely to offer other imaging services in their communities. METHODS: Linking data from the American Hospital Association's annual hospital surveys and the American Hospital Directory's annual surveys from 2009 to 2011, multivariate logistic regressions were performed to estimate the likelihood of individual CAHs with greater financial resources or network affiliations providing specific imaging services (MRI, CT, ultrasound, mammography, and PET/CT), while adjusting for the number of beds, personnel, inpatient revenue share, case mix, rural status, year, and geographic location. RESULTS: Hospital total expenditures were positively associated with the provision of MRI (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19), mammography (OR, 1.11; 95% CI, 1.01-1.16), and PET/CT (OR, 1.04; 95% CI, 1.01-1.06). Network affiliation was positively associated with the availability of MRI (OR, 1.75; 95% CI, 1.27-2.39), CT (OR, 2.17; 95% CI, 1.15-4.09), ultrasound (OR, 2.03; 95% CI, 1.17-3.52), and mammography (OR, 2.00; 95% CI, 1.47-2.71). Rural location was negatively associated with the availability of PET/CT (OR, 0.65; 95% CI, 0.49-0.88). CONCLUSIONS: Total hospital expenditures and network participation are important determinants of whether CAHs provide certain imaging services. Encouraging CAHs' participation in larger systems or networks may facilitate access to highly specialized services in rural and underserved areas.

Converting to critical access status: how does it affect rural hospitals' financial performance?

To improve rural access to care, the Balanced Budget Act of 1997 allowed eligible rural hospitals to convert to critical access hospitals (CAHs), which changed their Medicare payment from a prospective payment system (PPS) to a cost-based system. The objective of this paper is to examine the effects of CAH conversion on rural hospital operating revenues, operating expenses, and operating margins using an eight-year panel of 89 rural hospitals in Iowa. Ad hoc hospital revenue, cost, and profit functions were estimated using panel data fixed-effects linear models. We found that rural hospital CAH conversion was associated with significant increases in hospital operating revenues, expenses, and margins.

Factors associated with Iowa rural hospitals' decision to convert to critical access hospital status.

CONTEXT: The Balanced Budget Act (BBA) of 1997 allowed some rural hospitals meeting certain requirements to convert to Critical Access Hospitals (CAHs) and changed their Medicare reimbursement from prospective to cost-based. Some subsequent CAH-related laws reduced restrictions and increased payments, and the number of CAHs grew rapidly. PURPOSE: To examine factors related to hospitals' decisions to convert and time to CAH conversion. METHODS: Eighty-nine rural hospitals in Iowa were characterized and observed from 1998 to 2005. Cox proportional hazards models were used to identify the determinants of time to CAH conversion. FINDINGS: T-test and one-covariate Cox regression indicated that, in 1998, Iowa rural hospitals with more staffed beds, discharges, and acute inpatient days, higher operating margin, lower skilled swing bed days relative to acute days, and located in relatively high density counties were more likely to convert later or not convert before 2006. Multiple Cox regression with baseline covariates indicated that lower number of discharges and average length of stay (ALOS) were significant after controlling all other covariates. CONCLUSION: Iowa rural hospitals' decisions regarding CAH conversion were influenced by hospital size, financial condition, skilled swing bed days relative to acute days, length of stay, proportion of Medicare acute days, and geographic factors. Although financial concerns are often cited in surveys as the main reason for conversion, lower number of discharges and ALOS are the most prominent factors affecting rural hospitals' decision on when to convert.

Rural trauma: is trauma designation associated with better hospital outcomes?

CONTEXT: While trauma designation has been associated with lower risk of death in large urban settings, relatively little attention has been given to this issue in small rural hospitals. PURPOSE: To examine factors related to in-hospital mortality and delayed transfer in small rural hospitals with and without trauma designation. METHODS: Analysis of data from the Nationwide Inpatient Sample for discharges between 1998 and 2003 of patients hospitalized with moderate to major traumatic injury in nonfederal, short-stay rural hospitals with annual discharges of 1,500 or fewer patients (N = 9,590). Logistic regression was used to control for patient and hospital characteristics, stratifying by hospital volume. Main outcome measures were in-hospital death and transfer to another acute care facility after initial admission. FINDINGS: A total of 333 patients (3.5%) died in-hospital. After adjusting for patient, injury and hospital characteristics, in-hospital death was more likely among patients treated at the non-designated hospitals with fewer than 500 discharges per year (OR 2.35; 95% CI 1.25-4.41) than among patients treated at similar trauma-designated hospitals. Patients admitted to non-designated hospitals were more likely to be transferred after admission, although this finding was significant only in the larger-volume hospitals with discharges of 500-1,500 per year (OR 1.41, 95% CI 1.08-1.83). CONCLUSIONS: Associations between trauma designation and outcomes in rural hospitals warrant further study to determine whether expanding designation to more rural hospitals might lead to further improvement in trauma outcomes.

A rural crossroad.

The critical access hospital program is one of the few positive things for hospitals to come out of the 1997 Balanced Budget Act. It has meant salvation for the nearly 1,200 hospitals that have received the designation, and enables them to invest in facility upgrades, new equipment and additional staff. But a revamped Medicare managed care initiative threatens their payments and the Centers for Medicare & Medicaid Services and the Medicare Payment Advisory Program are taking a hard look at the program's costs. Some observers fear changes could be proposed that would weaken the CAH program.

Where's the money?

Small, rural hospitals don't necessarily need to put off needed renovations or the purchase of new technology or equipment. Contrary to what administrators and trustees might think, size and location does not preclude small rurals from obtaining needed capital.

Impact of conversion to critical access hospital status for Oklahoma's rural hospitals.

CONTEXT: The Medicare Rural Hospital Flexibility Grant Program established a new hospital category, the Critical Access Hospital, designed to provide financial stability to small rural hospitals that were losing money after changes in the Prospective Payment System implemented by Medicare. PURPOSE: This article describes the impact of conversion to Critical Access Hospital (CAH) status for 15 small rural hospitals in Oklahoma. Objectives of the study were to identify how conversion to CAH affected hospital utilization and finances for the first year after conversion. METHODS: A telephone survey was used to collect information from hospital administrators. Fifteen of 16 eligible hospitals participated in the study. FINDINGS: In general, services and patient census declined slightly with conversion to CAH. All 15 hospitals had reported losses prior to conversion, totaling $6,985,033. Ten hospitals reported losses after conversion. After converting to CAH status, the hospitals reported total losses of $3,094,547. The hospitals had a net change of $4,293,040. CONCLUSIONS: Most of the 15 study hospitals greatly improved their financial situation in the first year after conversion to CAH status, but in aggregate still operated at a loss.

The Utah rural residency study: a blueprint for evaluating potential sites for development of a 4-4-4 family practice residency program in a rural community.

CONTEXT: Most graduates of rural residencies enter rural practice. Rural residencies therefore have emerged over the past 2 decades to increase the supply of rural physicians. However, researchers have published few descriptions of strategies to evaluate and select communities in which to locate rural residencies. PURPOSE: This report describes the development and application of such a strategy to assess 7 rural communities in Utah as potential sites for family practice residency training. METHODS: Criteria were developed on the basis of an examination of the literature, residency accreditation requirements, and characteristics of existing rural residency programs. Ten rural or frontier communities with hospitals were selected as study candidates, and 7 agreed to participate. Data were collected through hospital surveys, state hospital discharge records, and community site visits. FINDINGS: Specific evaluation criteria that were developed included the presence of a medical practice of the appropriate specialty and size, a sufficient number of medical subspecialty physicians, an adequate number and mix of hospitalized patients, an adequate number of ambulatory patients, adequate outpatient facility space to accommodate learners, and a commitment by the practicing physician and hospital to lead the program and teach residents. Two communities were found to be potentially capable of supporting a residency if physicians and hospital leaders in the communities were to become motivated to lead program development. CONCLUSIONS: These criteria may be useful in other states, but they have not been tested for validity or reliability and are subject to limitations such as exclusion of alternate rural residency models. Future research should address data needs and the relationship of the evaluation criteria to the quality of resident learning.

CAH designation earns deemed status.

Earning JCAHO's Critical Access Hospital designation is challenging. Learn what it takes to receive it.

Choosing to convert to critical access hospital status.

The authors profile facilities converting to critical access hospitals (CAHs) from 1998-2000, comparing characteristics of their communities, operations, and finances to those of other small rural providers. Counties where CAHs are located are more sparsely populated, but do not have substantially different sociodemographic profiles than other rural counties. Converting hospitals' acute daily census averaged well below the statutory limit of 15, but over one-half reduced unused bed capacity to meet CAH size limitations. The average case-mix adjusted Medicare cost per case was 16-percent higher for CAH converters than for other small hospitals and their financial ratios were substantially worse, although many other operating characteristics were similar.