University of Iowa Quality Improvement Symposium Poster Presentation

By: Nabil Natafgi

PhD student, Nabil Natafgi, recently presented a poster at the fourth annual University of Iowa Quality Improvement Symposium. Background information and findings of the study presented in the poster are as follows:

Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?

Nabil Natafgi, MPH; Jure Baloh, MHA; Paula Weigel, PhD; Fred Ullrich ,BS; Marcia M. Ward, PhD

Research Objective: Critical Access Hospital (CAH) are the predominant type of hospitals operating in small and isolated rural areas, constituting approximately 27% of all community hospitals in the US. The intent of CAH designation is to reduce financial vulnerability of rural hospitals by providing a payment system based on cost, as opposed to prospective payment system (PPS) – the predominant reimbursement model for larger urban-centered hospitals. Such financial incentives are believed to improve access to healthcare by keeping essential services in rural communities. This study aims to examine whether CAHs perform better than, the same as, or worse than PPS hospitals on measures of quality.

Study Design: The Healthcare Cost and Utilization Project State Inpatient Databases and American Hospital Association annual survey data were used for analyses. Outcome measures included six bivariate indicators of adverse events of surgical care developed from the Agency for Healthcare Research and Quality’s Patient Safety Indicators (PSIs). Multiple logistic regression models were developed to examine the relationship between hospital adverse events and CAH status. Population Studied: A total of 35,674 discharges from 136 nonfederal general hospitals with fewer than 50 beds were included in the analyses: 14,296 from 100 CAHs and 21,378 from 36 PPS hospitals.

Principal Findings: Compared to PPS hospitals, CAHs are significantly less likely to have any observed (unadjusted) adverse event on four of the six indicators. After adjusting for patient mix and hospital characteristics, CAHs perform better on three of the six indicators. PPS hospitals were 7.7 times more likely to have any perioperative hemorrhage or hematoma event compared to CAH hospitals with similar patient mixes, accreditation and system membership status, and RN staffing ratios (P < 0.001). PPS hospitals were 4.3 times more likely to have any perioperative pulmonary embolism or deep vein thrombosis event compared to CAH hospitals (P = 0.002), and 9.1 times more likely to have any postoperative sepsis case compared to CAHs with comparable characteristics (P = 0.010). Accounting for the number of discharges eliminated the differences between CAHs and PPS hospitals in the likelihood of adverse events across all indicators except one. Patients were 6.3 times more likely to experience a perioperative hemorrhage or hematoma event in PPS hospitals than in CAHs after adjusting for patient mix, hospital characteristics, and number of discharges (P = 0.005).

Conclusions: The study suggests there are no differences in surgical patient safety outcomes between CAHs and PPS hospitals of comparable size.

Implications for Policy or Practice: This study has considerable policy relevance in light of recent research showing conflicting conclusions about quality of care in CAHs, and because health care reimbursement is increasingly shifting to payment for reported outcomes and quality improvement efforts. The findings reinforce the central role of CAHs in providing care to disadvantaged populations in rural and isolated areas, and underscore the importance of strategies to sustain rural surgery infrastructure.

Full-text available at: Natafgi, N., Baloh, J., Weigel, P., Ullrich, F. and Ward, M. M. (2016), Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?. The Journal of Rural Health. doi: 10.1111/jrh.12176