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Low patient volume and reimbursement issues drive closures.

Rural hospitals play a crucial role in providing health care to rural Americans, a vulnerable and underserved population; however, rural hospitals have faced threats to their financial viability and many have closed as a result. This paper examines the hospital characteristics that are associated with patients choosing rural hospitals, and sheds light on the types of patients who depend on rural hospitals for care and, hence, may be the most harmed by the closure of rural hospitals. Using data from California hospitals, the paper shows that patients were more likely to choose nearby hospitals, larger hospitals, and hospitals that offered more services and technologies. However, even after adjusting for these factors, patients had a propensity to bypass rural hospitals in favor of large urban hospitals. Offering additional services and technologies would increase the share of rural residents choosing rural hospitals only slightly.

Background and Purpose Stroke networks have been installed to increase access to advanced stroke specific treatments like mechanical thrombectomy (MT). This concept often requires patients to be transferred to a comprehensive stroke center (CSC) offering MT. Do patient referral, transportation, and logistic effort translate into clinical outcomes comparable to patients admitted primarily to the CSC? Material and Methods We categorized 112 patients with acute ischemic stroke in the anterior circulation, who received MT at our institution, into primary admissions (A) and referrals from either local (B) or regional (C) hospitals, assessed the clinical outcome, and tested the impact of distance and delay of transportation from the referring remote hospital. Results The median time from symptom onset to initial CT was similar in all groups ( p  = 0,939). Patients who were transferred to the CSC had significantly increasing median time between initial CT and MT (in minutes (interquartile range [IQR]); A: 83 [68–120]; B: 174 [159–208]; C: 220 [181–235]; p  < 0.001) and median time between onset to MT (in minutes [IQR]; A: 178 [150–210]; B: 274 [238–349]; C: 293 [256–329]; p  < 0.001). After 90 days of MT there was no significant difference in clinical outcome (modified Rankin Scale ≤ 2) between primary admitted and referred patients ( p  = 0.502). Conclusion Clinical outcome in patients who received MT after transfer from either local or regional remote hospitals was not significantly worse than in patients primarily admitted to the CSC. In the event of an acute ischemic stroke patients living in urban or rural areas should, despite a possible delay, have access to MT.

Most of the global neonatal deaths occur in developing nations, mostly in rural homes. Many of the newborns who receive formal medical care are treated in rural district hospitals and other peripheral health centres. However there are no published studies demonstrating trends in neonatal admissions and outcome in rural health care facilities in resource poor regions. Such information is critical in planning public health interventions. In this study we therefore aimed at describing the pattern of neonatal admissions to a Kenyan rural district hospital and their outcome over a 19 year period, examining clinical indicators of inpatient neonatal mortality and also trends in utilization of a rural hospital for deliveries. Prospectively collected data on neonates is compared to non-neonatal paediatric (≤ 5 years old) admissions and deliveries' in the maternity unit at Kilifi District Hospital from January 1(st) 1990 up to December 31(st) 2008, to document the pattern of neonatal admissions, deliveries and changes in inpatient deaths. Trends were examined using time series models with likelihood ratios utilised to identify indicators of inpatient neonatal death. The proportion of neonatal admissions of the total paediatric ≤ 5 years admissions significantly increased from 11% in 1990 to 20% by 2008 (trend 0.83 (95% confidence interval 0.45-1.21). Most of the increase in burden was from neonates born in hospital and very young neonates aged < 7 days. Hospital deliveries also increased significantly. Clinical diagnoses of neonatal sepsis, prematurity, neonatal jaundice, neonatal encephalopathy, tetanus and neonatal meningitis accounted for over 75% of the inpatient neonatal admissions. Inpatient case fatality for all ≤ 5 years declined significantly over the 19 years. However, neonatal deaths comprised 33% of all inpatient death among children aged ≤ 5 years in 1990, this increased to 55% by 2008. Tetanus 256/390 (67%), prematurity 554/1,280(43%) and neonatal encephalopathy 253/778(33%) had the highest case fatality. A combination of six indicators: irregular respiration, oxygen saturation of <90%, pallor, neck stiffness, weight < 1.5 kg, and abnormally elevated blood glucose > 7 mmol/l predicted inpatient neonatal death with a sensitivity of 81% and a specificity of 68%. There is clear evidence of increasing burden in neonatal admissions at a rural district hospital in contrast to reducing numbers of non-neonatal paediatrics' admissions aged ≤ 5 years. Though the inpatient case fatality for all admissions aged ≤ 5 years declined significantly, neonates now comprise close to 60% of all inpatient deaths. Simple indicators may identify neonates at risk of death.

The response of trauma systems in rural areas is uncertain since distances between injury scenes and trauma care are considerable. Timely arrival at definitive care is critical for persons with traumatic brain injury (TBI) since secondary damage can occur during the hours following injury. We evaluated how the implementation of a trauma system in a predominately rural state affected the triage of TBI patients and their risk for mortality. The Iowa System Trauma Registry Dataset was analyzed, and included patients evaluated before trauma system implementation, 1997-1998, and after implementation, 2002-2003. Patients were identified using ICD9-CM codes or AIS codes, and included 710 pre-system patients and 886 post-system patients. Multivariate logistic regression assessed the effect of the trauma system on survival while controlling for confounders. Following implementation of the trauma system, patients treated in Level I or II facilities were older (p = 0.019), more often had multiple injuries (p = 0.0002), and had more severe TBI (p = 0.008). After controlling for confounders, transferred patients and those directly admitted were less likely to die in 72 h in the post-system than the pre-system (odds ratio [OR] = 0.56, 95% confidence interval (CI) = 0.36, 0.88; OR = 0.50, 95% CI = 0.32, 0.79). Implementation of the Iowa trauma system seems to have led to more appropriate triage and transport for TBI patients, and this likely contributed to reduced in-hospital mortality.

Background To reduce the burden of out-of-pocket payments on households in India, the government has introduced community health insurance (CHI) as part of its National Rural Health Mission. Indian CHI schemes have been shown to provide financial protection and have the potential to improve quality of care, but do not seem to improve access. This study examines this dimension of CHI performance and explores conditions under which a CHI scheme can improve access to hospital care for the poor. Methods We conducted a panel survey at the ACCORD-AMS-ASHWINI (AAA) CHI scheme in India. The AAA CHI scheme protects the poorest sections of society against hospitalization expenses. 297 insured and 248 matched uninsured households were observed by village volunteers on a weekly basis for 12 months. Any patient presenting with a ‘major ailment’ in these households was interviewed using a structured questionnaire. Outcomes measured were utilization of hospital services, cost of treatment and quality of treatment received. Results The two cohorts were similar regarding demographic, social and economic parameters. More insured than uninsured households expressed trust in the CHI scheme organizers. Both groups had similar levels of minor ailments, but the insured had higher incidence of chronic and major ailments. Insured patients had a hospital admission rate 2.2 times higher than uninsured patients, independent of confounding factors. This higher rate among the insured was also found in children and those with pre-existing conditions. Vulnerable sections of the insured population—children, pregnant women, the poorest—had the highest admission rates. Most admissions, in both cohorts, took place in the ASHWINI hospital. Credible and trustworthy organizers, effective providers, low co-payments, and low indirect costs contributed to this result. Conclusions A well-designed CHI scheme has the potential to improve access to hospital care, even for vulnerable sections of the community—the poorest, individuals with pre-existing conditions like diabetes and hypertension, and pregnant women.

Using data from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, we examined the magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs). An estimated $9.5 billion in charges incurred in rural hospitals nationwide in 2002 was found to be associated with hospitalizations due to ACSCs. Our findings suggest that the smaller a rural hospital, the greater the portion of its financial resources used to treat patients with ACSC. Regional variation in ACSC-related hospital charges is generally consistent with the geographic variation in the population's economic status and primary care physician supply—residents of the South region have the poorest access to primary healthcare. In summary, smaller rural communities spend more of their healthcare resources on avoidable hospital inpatient care than do larger rural communities, leaving smaller rural communities potentially fewer resources to spend on preventive and primary healthcare. Health intervention programs and health policies should be designed to increase access to and utilization of appropriate preventive and primary healthcare in rural areas, especially in small and remote communities.

Drug related-soft tissue infections (DR-STIs) are a significant source of hospital utilization in inner-city urban areas where injection drug use is common but the magnitude of hospital utilization for DR-STIs outside of inner-city urban areas is not known. We described the magnitude and characteristics of hospital utilization for DR-STIs in urban versus rural counties in California. All discharges from all nonfederal hospitals in California in 2000 with ICD-9 codes for a soft tissue infection and for drug dependence/abuse were abstracted from the California Office of Statewide Health Planning and Development discharge database. There were 4,152 DR-STI discharges in 2000 from hospitals in 49 of California's 58 counties. Residents of 12 large metropolitan counties accounted for 3,598 discharges (87% of total). The majority of DR-STI discharges were from urban safety net hospitals with county indigent programs and Medicaid as the expected payment source and opiate related discharge diagnoses. Hospital utilization for DR-STIs in California is highest in large urban metropolitan counties, although DR-STI discharges are widespread. Increased access to harm reduction services and drug treatment may reduce government health care expenditures by preventing unnecessary hospital utilization for DR-STIs.