Department of Urology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
JAMA Surg. 2013 Jul;148(7):589-96. doi: 10.1001/jamasurg.2013.1224.
There is a growing interest in the quality and cost of care provided at Critical Access Hospitals (CAHs), a predominant source of care for many rural populations in the United States.
To evaluate utilization, outcomes, and costs of inpatient surgery performed at CAHs.
DESIGN, SETTING, AND PATIENTS: A retrospective cohort study of patients undergoing inpatient surgery from 2005 through 2009 at CAHs or non-CAHs was performed using data from the Nationwide Inpatient Sample and American Hospital Association.
The CAH status of the admitting hospital.
In-hospital mortality, prolonged length of stay, and total hospital costs.
Among the 1283 CAHs and 3612 non-CAHs reporting to the American Hospital Association, 34.8% and 36.4%, respectively, had at least 1 year of data in the Nationwide Inpatient Sample. General surgical, gynecologic, and orthopedic procedures composed 95.8% of inpatient cases at CAHs vs 77.3% at non-CAHs (P < .001). For 8 common procedures examined (appendectomy, cholecystectomy, colorectal cancer resection, cesarean delivery, hysterectomy, knee replacement, hip replacement, and hip fracture repair), mortality was equivalent between CAHs and non-CAHs (P > .05 for all), with the exception that Medicare beneficiaries undergoing hip fracture repair in CAHs had a higher risk of in-hospital death (adjusted odds ratio = 1.37; 95% CI, 1.01-1.87). However, despite shorter hospital stays (P ≤ .001 for 4 procedures), costs at CAHs were 9.9% to 30.1% higher (P < .001 for all 8 procedures).
In-hospital mortality for common low-risk procedures is indistinguishable between CAHs and non-CAHs. Although our findings suggest the potential for cost savings, changes in payment policy for CAHs could diminish access to essential surgical care for rural populations.
对于美国许多农村地区人口的主要医疗来源的关键通道医院（CAHs）所提供的护理质量和成本，人们的兴趣日益浓厚。
评估在 CAHs 进行的住院手术的利用情况、结果和成本。
设计、设置和患者：使用来自全国住院样本和美国医院协会的数据，对 2005 年至 2009 年期间在 CAHs 或非 CAHs 接受住院手术的患者进行了回顾性队列研究。
收治医院的 CAH 状态。
院内死亡率、住院时间延长和总住院费用。
在向美国医院协会报告的 1283 家 CAHs 和 3612 家非 CAHs 中，分别有 34.8%和 36.4%在全国住院样本中至少有 1 年的数据。普通外科、妇科和骨科手术占 CAHs 住院病例的 95.8%，而非 CAHs 为 77.3%（P<.001）。对于检查的 8 种常见手术（阑尾切除术、胆囊切除术、结直肠癌切除术、剖宫产术、子宫切除术、膝关节置换术、髋关节置换术和髋关节骨折修复术），CAHs 和非 CAHs 之间的死亡率相当（所有手术 P>.05），但 Medicare 受益人为髋部骨折修复术在 CAHs 住院的患者院内死亡风险更高（校正比值比=1.37；95%置信区间，1.01-1.87）。然而，尽管住院时间较短（P≤.001，对于 4 种手术），但 CAHs 的费用却高出 9.9%至 30.1%（对于所有 8 种手术，P<.001）。
对于常见的低风险手术，CAHs 和非 CAHs 之间的院内死亡率无差异。尽管我们的研究结果表明存在节省成本的潜力，但 CAHs 支付政策的变化可能会减少农村地区获得基本手术护理的机会。
