Rural hospitals shown to provide quality care for patients with heart attacks

Contrary to some previous studies, rural hospitals in Iowa do provide quality care for patients with heart attacks and do not have higher death rates when compared to urban hospitals, report University of Iowa researchers.

The study, which was based on data from 119 urban and rural hospitals in Iowa, used a different, more sensitive analytic method than previous research approaches. The findings appear in the March/April issue of the Annals of Family Medicine .

Rating hospitals' quality of care for diseases such as heart attacks is a rising trend in the United States. However, the ratings need to be accurate, said Paul James, M.D., professor and head of family medicine in the UI Roy J. and Lucille A. Carver College of Medicine.

"Traditional methods of analysis indicated that rural hospitals have higher death rates for heart attack care than do urban hospitals, but we suspected there were problems with that data," said James, who also holds the Iowa Academy of Family Physicians Endowed Chair in Rural Medicine.

"The older approaches did not take certain biases, or confounding factors, into consideration, and so comparing rural to urban hospitals was like comparing apples to oranges. We used an approach that allowed us to study patients that were comparable who attended rural and urban hospitals," he added.

The team used year 2002 and 2003 Iowa State Inpatient Datasets, which included information on 12,191 admissions for people age 18 older diagnosed primarily with a heart attack.

Rural hospitals can provide some life-saving measures and have the role of triaging heart attacks cases, which could result in a patient being transported to an urban hospital. Yet, in some cases, a patient's family may, in consultation with a physician at a rural hospital, choose not to send a family member who has had a heart attack to an urban hospital. For example, if the patient is elderly and has other, complicated health conditions, the family may want the person to stay closer to home and support networks.

Thus, the UI study attempted to control for the finding that the sickest heart attack patients may stay at rural hospitals while the healthiest are transferred to an urban hospital.

"Some patients with heart attacks have complicated conditions, such as a 90-year-old man who also has dementia and lung disease. In such cases, based on patient preferences, it may be appropriate for that patient not to be transferred to a large, urban hospital," James said.

"Our study took into consideration that the traditional techniques to measure hospital heart attack care were not properly sensitive to the type of patients admitted to the rural hospitals and did not take into account the important role that physicians play in directing patients from a rural hospital to a more advanced, urban hospital," James added.

James said that rating hospitals is becoming more common due to federal government and Medicare/Medicaid emphasis on paying hospitals for performance.

"Some agencies judge the quality of a hospital based on mortality rates without understanding the factors that contribute to those rates. Quality indicator ratings are not the be-all and end-all, especially if the analysis does not appropriately measure all factors," James cautioned. "One needs to take into account many factors such as surrounding community, location and purpose of the hospital."

While the UI study was limited to Iowa hospitals, investigators aim next to analyze a nationwide hospital dataset or datasets from other states.

In addition to James, the study team included Pengxiang Li, research assistant in health management and policy in the UI College of Public Health, and Marcia Ward, Ph.D., UI professor of health management and policy and a member of the Center for Research in the Implementation of Innovative Strategies in Practice at the Veterans Affairs Iowa City Health Care System.

The study was funded in part by a grant from the Agency for Healthcare Research and Quality, part of the U.S Department of Health and Human Services.