Date of Degree
PhD (Doctor of Philosophy)
Health Management and Policy
Ward, Marcia M.
First Committee Member
Mueller, Keith J.
Second Committee Member
Third Committee Member
Vaughn, Thomas E.
Fourth Committee Member
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.
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 annually. Despite the success of some policies in protecting access to critical care for rural populations, we have little and conflicting evidence about the quality of inpatient care provided in CAHs. Furthermore, small safety-net hospitals often find it difficult to provide emergency services with limited resources. Telemedicine has the potential to address these challenges by providing clinical support that allows CAH providers to improve health outcomes while overcoming geographic barriers and resource constraints in rural areas.
This dissertation examines three aspects of care delivery in CAHs – effectiveness, access, and cost/efficiency. The first study measures the performance of CAHs on specific patient safety indicators and concludes that there are no differences in the quality of surgical care provided in CAHs and hospitals of comparable size. The second study evaluates the impact of a rural-ED- based telemedicine program on access to health care and finds that the use of telemedicine in a CAH makes it less like that a patient will have to be admitted, but does not directly affect routine discharges or transfers. Lastly, the third paper addresses costs of care and concludes that telemedicine has the potential to reduce the number of transfers of ED patients and generate substantial savings for patients, despite associated technology costs.
Findings from this dissertation reaffirm the central role of CAHs in providing care to disadvantaged populations in rural and isolated areas, and underscores the importance of strategies to sustain rural care infrastructure.
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
Natafgi, Nabil M.. "Improving care delivery in critical access hospitals: evaluating the quality environment and the 'critical' role of telemedicine on access and costs." PhD (Doctor of Philosophy) thesis, University of Iowa, 2017.