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Original Investigation |

Transfer Rates and Use of Post–Acute Care After Surgery At Critical Access vs Non–Critical Access Hospitals

Adam J. Gadzinski, MD, MS1; Justin B. Dimick, MD, MPH2,3; Zaojun Ye, MS1; John L. Zeller, MD, PhD4,5,6; David C. Miller, MD, MPH1,3
[+] Author Affiliations
1Department of Urology, University of Michigan Health System, Ann Arbor
2Department of Surgery, University of Michigan Health System, Ann Arbor
3Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan Health System, Ann Arbor
4Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor
5Department of Emergency Medicine, University of Michigan Health System, Ann Arbor
6Department of Medical Education, University of Michigan Health System, Ann Arbor
JAMA Surg. 2014;149(7):671-677. doi:10.1001/jamasurg.2013.5694.
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Importance  There is growing interest in the use of health care resources by critical access hospitals (CAHs), key providers of medical care for many rural populations.

Objective  To evaluate discharge practice patterns and use of post–acute care after surgical admissions at CAHs.

Design, Setting, and Participants  We used data from the Nationwide Inpatient Sample (2005-2009) and American Hospital Association to perform a retrospective cohort study of patients undergoing common inpatient surgical procedures at CAHs or non-CAHs.

Exposures  The CAH status of the admitting hospital.

Main Outcomes and Measures  Hospital transfer, discharge with post–acute care, or routine discharge.

Results  Among the 1283 CAHs and 3612 non-CAHs included in the American Hospital Association annual survey, 34.8% and 36.4%, respectively, reported data to the Nationwide Inpatient Sample. For each of 6 common inpatient surgical procedures, a greater proportion of patients from CAHs were transferred to another hospital (P < .01); however, patients discharged from CAHs were less likely to receive post–acute care for all but 1 of the procedures examined (P < .01, except transurethral resection of prostate, P = .76). After adjustment for patient and hospital factors, the higher likelihood of transfer by CAHs vs non-CAHs persisted for 3 procedures: hip replacement (odds ratio, 1.90; 95% CI, 1.01-3.57), colorectal cancer resection (3.37; 2.23-5.09), and cholecystectomy (1.67; 1.27-2.19) (P < .05 for each), but differences in the use of post–acute care did not. In subset analyses, Medicare beneficiaries treated in CAHs were less likely to be discharged with post–acute care after hip fracture repair (odds ratio, 0.65; 95% CI, 0.47-0.89) and hip replacement (0.70; 95% CI, 0.51-0.96).

Conclusions and Relevance  Hospital transfers occur more often after surgical admissions at CAHs. However, the proportion of patients at CAHs using post–acute care is equal to or lower than that of patients treated in non-CAHs. These results will affect the ongoing debate concerning CAH payment policy and its implications for health care delivery in rural communities.

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Figure 1.
Rates of Transfer (A) and Discharge With Post–Acute Care (B) by Surgical Procedure

Unadjusted rates are shown for critical access hospital (CAH) and non-CAH facilities. Transferred patients are excluded from discharge data. aP < .001; bP < .01. CRC indicates colorectal cancer; TURP, transurethral resection of prostate.

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Figure 2.
Adjusted Odds of Transfer From Critical Access Hospital (CAH) Facilities by Surgical Procedure

A, All patients. B, Patients with Medicare as the primary payer. C, Patients admitted to rural hospitals. Comparisons are adjusted for patient variables and hospital characteristics; non-CAH patients are the referents. Error bars and parenthetical ranges represent 95% CIs. CRC indicates colorectal cancer; TURP, transurethral resection of prostate.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Adjusted Odds of Discharge With Post–Acute Care From Critical Access Hospital (CAH) Facilities by Surgical Procedure

A, All patients. B, Patients with Medicare as the primary payer. C, Patients admitted to rural hospitals. Comparisons are adjusted for patient variables, hospital characteristics, and geographic location of hospital; transferred patients are excluded, and non-CAH patients are the referent. Error bars and parenthetical ranges represent 95% CIs. CRC indicates colorectal cancer; TURP, transurethral resection of prostate.

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