Rural-Urban differences in hospital performance in the United States: The role of hospital characteristics

Many studies have shown that inpatient care quality varies significantly depending on where the patients live and seek care. The purpose of this study is twofold: to determine the differences in hospital care quality between rural and urban areas using 2008 CMS Hospital Compare Data; and to examine the role of hospital characteristics in rural-urban differences in hospital care quality. We assessed hospital quality for 3 clinical conditions: acute myocardial infarction (AMI), heart failure, and pneumonia by using both standardized process and outcome measures. Seventeen process measures for the period of January to December 2008 were analyzed, among which seven were related to AMI, four related to heart failure, and six related to pneumonia. Two outcome measures covering the period of July 2005 to June 2008 were: risk-adjusted hospital 30-day mortality rates and hospital 30-day readmission rates for all three clinical conditions. We categorized hospitals using the 2003 Rural-Urban Continuum Codes (RUCC) system developed by the US Department of Agriculture's Economic Research Service classifying rural and urban areas. Hospitals are categorized as rural hospitals (if located in rural areas) or urban hospitals (if located in urban areas). American Hospital Association Annual Survey data of 2003 is utilized to examine the role of hospital characteristics in rural-urban differences in hospital quality. Hospital characteristics included are: hospital profit status, number of beds, teaching status, accreditation status, and the percentage of Medicaid patients (payer mix). The final data analyses in this study included 4488 eligible hospitals in the United States, among which, 2712 (60.4%) are urban hospitals and 1776 (39.6%) are rural hospitals. More than 89% of urban hospitals are accredited versus 56% of rural hospitals. In rural areas about 11% hospitals are for profit, 54% not for profit, and 34% government hospitals. In urban areas 20% are for profit, 64% not for profit and 16% are government hospitals. Controlling for hospital characteristics, in 2008, except for “pneumonia patients given initial antibiotic(s) within 6 hours after arrival” the performance of rural hospitals lagged significantly behind urban hospitals on all process measures. From 2005 to 2008, hospital 30-day mortality rates were significantly higher in rural hospitals compared to urban hospitals for AMI, heart failure, and pneumonia. The readmission rate in rural hospitals was significantly higher for heart failure condition than in urban hospitals. There was no significant difference in 30-day hospital readmission rates for AMI and pneumonia between rural and urban hospitals.