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Harvard Study Puts Maine's Rural Hospitals on Defensive
07/14/2011   Reported By: Jay Field

Officials responsible for ensuring that patients in small rural hospitals get safe, reliable care are taking issue with how a recent national study portrayed their efforts. The report--written by Harvard researchers and published in the Journal of the American Medical Association--paints a stark picture of the risks patients face at so-called critical access hospitals. Those who monitor care at rural hospitals and provide it---in Maine and elsewhere---argue the study failed to document how much progress has actually been made improving conditions for patients.

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Critical access hospitals--or CAHs--are geographically isolated and have no more than 25 beds. There are now about 1,300 of them nationwide. Maine has 15. They account for more than a quarter of all acute care hospitals U.S. And up until very recently, these rural hospitals were exempt from national programs that their larger, urban counterparts take part in, monitoring the quality of patient care.

"So we really set out to try to understand these hospitals," says Dr. Karen Joynt, a cardiologist at Brigham and Women's Hospital in Boston. Joynt led the Harvard School of Public Health's investigation of care at rural hospitals.

Joynt and her colleagues analyzed the medical records of more than two million Medicare patients at nearly 5,000 hospitals---27 percent of which were CAHs. They also looked at how much money and clinical staff these hospitals had to do their jobs.

"And we found that hospitals with the critical access designation had a lower level of resources, in terms of the clinical care they could provide. They also had lower performance on processes of care--things like giving aspirin for heart attacks or giving antibiotics in a timely fashion for pneumonia," Joynt says. "We also found that patients that were admitted to a critical access hospital had a higher 30-day mortality rate for heart attacks, heart failure and pneumonia."

The Harvard study was the lead article in the Journal of the American Medical Association earlier this month. It was also the hot topic of conversation at an annual conference of rural hospital and health care officials in Portland earlier this week.

Ed Gamache gave a keynote address. He runs Harbor Beach Community Hospital, a CAH in rural Michigan.
"We're the ones who have to put the pictures out there, so people understand what we do and how well we do it. No one else is going to do it for us. Oh, by the way, there's a contest. Terry is going to give $1,000 to the person who correctly counts the number of times the JAMA article is mentioned over the next day and a half," he said to laughter.

One-on-one, though, there wasn't much laughing going on over the JAMA article. Ira Moscovice is a professor at the University of Minnesota School of Public Health. For the past several years, Moscovice and colleagues at the University of North Carolina and the University of Southern Maine have been working with the federal Office of Rural Health Policy to track overall performance at critical access hospitals.

"There's really no new news in the JAMA piece on CH quality," Moscovice says. "We still have a ways to go. we know that, if you look at most measures, that the quality of care in CAHs is a little bit lower than it is in non-critical access hospitals."

In the JAMA article, researchers write about how difficult it is for rural hospitals to take care of the older, sicker, more impoverished populations they see---with limited financial resources, fewer staff and a lack of the emergency rooms and other specialized units.

"What I take from that is somehow if we all look like hospitals in Boston, all critical access hospitals look like those hospitals, the world would be better off," Moscovice says. "It's simply not feasible. It's an inefficient way to look at the issue of--what we should be looking at is how can smaller, critical access hospitals best take advantege of the resources, the staffing that they have to produce high quality results."

Or, how can more rural hospitals becomes as good as Mayo Regional Hospital in Dover Foxcroft? Lynne Gagnon oversees patient care services at Mayo Regional.

"If you're willing to report and put your're statistics out there, you're going to work harder to make sure they compare and that you're providing the same level of care with the hospitals you're being compared with," Gagon says. "And if you look at the data in Maine, all fifteen CAHs report their data. And I would say that most of them could match up with the larger hospitals."

Perhaps none as well as Mayo Regional. The hospital was recently named one of the best in the entire state. Gagnon says getting all its medical records online has been a critical part of the hospital's improvement in recent years. Mayo Regional now uses a bar code scanning system to keep track of all medication that comes in and out of its pharmacy.

They're the sort of technological advancements that all rural hospitals are now under the gun to comply with as part of the new federal health care law.


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