The old part of the Beebe Hospital in Lewes, Delaware.

[imgcontainer right] [img:Beebe.jpg] [source]Mike Mahaffie[/source] The old part of the Beebe Hospital in Lewes, Delaware. [/imgcontainer]

Which is it, JAMA? Where is your consistency in articles regarding quality of care? 

One article, published in the Journal of the American Medical Association last year by Clemens Hong, notes the difficulty of separating the context of primary care of the underserved from the quality of care.

This is a landmark article, painstakingly difficult to complete, and it concluded that “greater proportions of underinsured, minority, and non–English-speaking patients were associated with lower quality rankings for primary care physicians.” 

Now JAMA has an article this year claiming lower quality of care in certain types of rural hospitals that are completely different in location, population, funding, and workforce – different by design.

The article was titled “Quality of Care and Patient Outcomes in Critical Access Rural Hospitals.” Researchers at Harvard report that they found that smaller, rural hospitals had “fewer clinical capabilities, worse measured processes of care, and higher mortality rates” for patients with heart attacks, congestive heart failure and pneumonia. 

So what happened between last year, when patients made the difference in quality, and this year when it was location of the hospital?

Why would a comparison of hospitals with the most and least in any number of dimensions be a good comparison, other than to demonstrate the inequities of U.S. health spending designs? 

Why would we expect anything else when care in rural areas involves consistently some of the most complex populations with the least access to care and the lowest concentrations of health care resources and workforces? How can we expect hospitals that are 75% to 85% dependent upon Medicare and Medicaid to look good when other hospitals have lower percentages of Medicare and Medicaid payments and receive higher reimbursements from Medicare, Medicaid, and other sources?

Why do sophisticated researchers, reviewers, and editors maximize the context of care sometimes (in 2010) and minimize it at other times (in 2011)? Is it perhaps because they fail to comprehend the importance of the patient and the context of care?

The article in JAMA prominently notes that critical access hospitals, those that are found in rural communities, have fewer resources. Any reader can understand that this could be a problem with regard to health care delivery. 

Do Harvard University researchers associated with hospitals with the most sources of income and the highest reimbursement rates even have the perspective to write about hospitals with the least lines of funding and the lowest reimbursement in each line? 

Do researchers understand the term “Critical Access” or the importance of local care to the community and to local workforce, not to mention the local economic impact of these hospitals?

[imgcontainer left] [img:criticalchart300.jpeg] [/imgcontainer]

Let’s do a comparison. Rural areas realize $1,400 per person in economic impact from office-based physicians. In urban zip codes, office-based physicians produce $10,000 per patient in economic impact.

If rural communities realized the same kinds of economic impact as urban areas, perhaps they would have a different quality of care and maybe patients in those places would have better jobs and higher incomes.  Perhaps those shaping JAMA should read American Medical Association reports on these kinds of discrepancies and attempt to comprehend what this means to those left behind — by design. 

JAMA should focus on the highest quality standards and as a medical journal it should consider the physician credo: First do no harm.

An article about higher and lower quality critical access hospitals would be a welcome addition to the literature and a great help in improving rural hospitals. Perhaps one of the problems with attempting such research is that there is little variation across rural hospitals. Perhaps that’s because the system is designed to spend uniformly less on health care across rural America.

We’ve seen these kinds of studies before and the end result of 100 years of such articles and reports is becoming clear:  

The end result is less care and less economic impact from healthcare in 30,000 zip codes with 65% of the U.S. population. And more care delivered in 3400 zip codes in 4% of the land area. 

Of course, you can always take a dare and find where rural hospitals and rural communities do better. For one, readmission rates. 

Readmission rates can be 25% for various heart disease areas. Much better outcomes are possible and have been demonstrated. Success was not about sophisticated technology guided by research. Low cost interventions involving interactions among people can reduce readmissions to near zero, thus maximizing hospital revenues. 

And rural areas excel in low-cost, highly personal care. That’s done by design. 

Dr. Robert C. Bowman, M.D., founder of the Rural Medical Educators Group of the National Rural Health Association, is a physician and long time health education policy advocate. He is professor in Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona. 

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