Surgical Procedures at Critical Access Hospitals within Hospital Networks.

OBJECTIVE
To compare surgical outcomes and expenditures at hospital network participating critical access hospitals to non-network participating critical access hospitals among Medicare beneficiaries.


SUMMARY AND BACKGROUND DATA
Critical access hospitals provide essential care to more than 80 million Americans. These hospitals, often rural, are located more than 35 miles away from another hospital and are required to maintain patient transfer agreements with other facilities capable of providing higher levels of care. Some have gone further to formally participate in a hospital network.


METHODS
Cross-sectional retrospective study from 2014-2018 comparing 16,128 Medicare beneficiary admissions at hospital network participating versus non-participating critical access hospitals undergoing appendectomy, cholecystectomy, colectomy, or hernia repair. Thirty-day mortality and readmissions were risk adjusted using multivariable logistic regression accounting for patient and hospital factors. Price-standardized, risk-adjusted Medicare expenditures were compared for the 30-day total episode payments consisting of index hospitalization, physician services, readmissions, and post-acute care payments.


RESULTS
Beneficiaries (average age=75.7 y, SD=7.4) who obtained care at hospital network participating critical access hospitals were more likely to carry ≥2 Elixhauser comorbidities (68.7%vs.62.8%, P<0.001). Rates of 30-day mortality were higher at hospital network participating critical access hospitals (4.30%vs.3.81%, OR=1.11, P<0.001). Similarly, readmission rates were higher at hospital network participating critical access hospitals (15.13%vs.14.34%, OR=1.06, P<0.001). Additionally, total episode payments were found to be $960 higher per patient at hospital network participating critical access hospitals ($23,878vs.$22,918, P<0.001).


CONCLUSION
Critical access hospitals within a hospital network provided care to more medically complex patients and were associated with worse clinical outcomes and higher costs among Medicare beneficiaries undergoing common general surgery operations.