Document Type


Date of Degree

Spring 2017

Access Restrictions

Access restricted until 07/13/2018

Degree Name

PhD (Doctor of Philosophy)

Degree In

Health Management and Policy

First Advisor

Marcia M. Ward


Critical Access Hospitals (CAHs) – the predominant type of hospital operating in rural areas – play an integral role in the US healthcare system, providing care for over 7 million rural residents each year who might otherwise have no local access to urgent care or inpatient services. This dissertation examines three aspects of care delivery in CAHs – effectiveness, cost/efficiency, and access – each of which has separate implications for policy and practice.

The first study addresses effectiveness and evaluates the performance of CAHs on specific patient safety indicators compared to small Prospective Payment System (PPS) hospitals. A total of 35,674 discharges from 136 non-federal general hospitals with fewer than 50 beds were included in the analyses: 14,296 from 100 CAHs and 21,378 from 36 PPS hospitals. Outcome measures included six bivariate indicators of adverse events of surgical care that were developed from Agency for Healthcare Research and Quality Patient Safety Indicators. Multiple logistic regression models were developed to examine the relationship between hospital adverse events and CAH status. The results indicated that compared to PPS hospitals, CAHs are less likely to have any observed (unadjusted) adverse event on all six indicators, four of which are statistically significant. After adjusting for patient mix and hospital characteristics, CAHs perform better on three of the six indicators. Accounting for the number of discharges eliminated the differences between CAHs and PPS hospitals in the likelihood of adverse events across all indicators except one.

Tele-emergency (tele-ED) services can address several challenges facing emergency departments (EDs) in rural areas. The second study investigates access and characterizes the impact of a rural-ED-based telemedicine program on discharge disposition in terms of patient transfer, local hospital admission, and routine discharge. This study tests the hypothesis that telemedicine enhances access by allowing patients to receive care in the local community, and does so by looking at the probability of transfer and local admissions before and after telemedicine was implemented in CAHs. The results indicate that in the post-telemedicine period, patients were 38% less likely to be admitted to the local inpatient facility than to be routinely discharged [aOR=0.62, 95%CI=(0.57,0.67)] after adjusting for age, sex, race, time of visit, clinical diagnosis, CPT code, number of diagnoses, and admitting hospital.

The third study addresses cost and efficiency by modeling the financial implications of using the same telemedicine program to avoid transfers and estimating the costs and benefits associated with tele-ED implementation in CAHs. Analysis is based on 9,048 tele-ED encounters generated by the Avera eEmergency program in 85 rural hospitals across seven states between October 2009 and February 2014. For each non-transfer patient, physicians indicated whether the transfer was avoided because of tele-ED activation. The cost-benefit analysis is conducted from the hospital, patient, and societal perspectives, and includes technology costs, local hospital revenues, and patient-associated savings. The results show that 1,175 avoided transfers could be attributed to tele-ED. From a rural hospital perspective, tele-ED costs around $1,739 to avoid a single transfer but saves approximately $5,563 in avoided transportation and indirect patient costs. From a societal perspective, tele-ED results in a net savings of $3,823 per avoided transfer while accounting for tele-ED technology costs, hospital revenues, and patient-associated savings. This study highlights various stakeholder perspectives on the financial impact of tele-ED in avoiding patient transfers in rural EDs. Telemedicine has the potential to reduce the number of transfers of ED patients and generate some revenue for rural hospitals despite associated technology costs, while incurring substantial patient savings.


Avoided transfers, Cost-effectiveness analysis, Critical Access Hospitals, Discharge disposition, Quality of care and patient safety, Telemedicine


xiii, 96 pages


Includes bibliographical references (pages 81-88).


Copyright © 2017 Nabil M. Natafgi

Available for download on Friday, July 13, 2018