MORE WITH LESS Critical access hospitals provide needed care to 20% of the U.S. population.

They may be small and off the beaten path, but critical access hospitals in rural areas beat larger hospitals when it comes to safety and cost savings associated with gallbladder removal, colon surgery, hernia repair and appendectomy, according to a study published in JAMA.

Researchers at the University of Michigan compared outcomes of the surgeries performed on Medicare beneficiaries at 828 critical access hospitals and 3,676 larger hospitals between 2009 and 2013. The results show that although the risk of mortality within 30 days of surgery was the same in both settings, the likelihood that patients would suffer post-op heart attack, pneumonia or kidney damage was lower at the critical access hospitals. In addition, each patient who underwent surgery at the smaller hospitals cost the Medicare system approximately $1,400 less than patients who underwent the same procedures at larger facilities.

The researchers concede that critical access hospitals care for healthier patients and send higher acuity patients to larger hospitals. However, the cost and safety advantages of the critical care hospitals held true after the researchers adjusted for pre-op health.

"From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing — performing common operations on appropriately selected patients who are safe to stay locally for their care," says Andrew Ibrahim, MD, the study's lead author and a VA-Robert Wood Johnson Clinical Scholar at the University of Michigan Medical School in Ann Arbor.

Hospitals qualify for the "critical access" designation under the Medicare Rural Hospital Flexibility Program if they have fewer than 25 inpatient beds and are more than 35 miles away from another hospital. By qualifying, the hospitals receive 101% of reasonable costs and are exempt from several limitations to Medicare payments. In addition, surgeons who care for Medicare patients at the facilities receive 115% of typical physician fees.

The Medicare Rural Hospital Flexibility Program is designed to subsidize the rural hospitals so they stay financially viable in remote areas where access to care is needed. However, several facilities across the country are still in danger of shuttering due to financial hardships.

"The goal of the rural surgeon is best care nearest home," says Tyler Hughes, MD, a general surgeon at the critical access facility McPherson Hospital in McPherson, Kans., and a director of the American Board of Surgery. "Data to show that the care in rural centers is both safe and cost effective is critical in the decisions the profession faces in providing care to the 20% of the U.S. population living in truly rural environments. This study gives credence to what rural surgeons long suspected — that well-done rural surgery is safe and cost effective."

Daniel Cook