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. 2025 May 16.
doi: 10.1097/SLA.0000000000006754. Online ahead of print.

Trends in Surgical Quality at Critical Access Hospitals

Cody Lendon Mullens  1   2   3 , Janice C Probst  4 , Patrick L Johnson  1   2 , Nicholas Kunnath  2 , Justin B Dimick  1   2 , Andrew M Ibrahim  1   2   5
Affiliations

Trends in Surgical Quality at Critical Access Hospitals

Cody Lendon Mullens et al. Ann Surg. .

Abstract

Objective: To longitudinally compare trends in quality of care for common surgical conditions at CAHs compared to non-CAHs.

Summary background data: Critical access hospitals (CAH) simultaneously face challenges of preserving access and ensuring quality. Data have identified concerns of quality over time for medical conditions, but less is understood about surgical care.

Design, setting, participants: Retrospective longitudinal cohort study of Medicare beneficiaries who underwent common surgical procedures between 2010 and 2020 including appendectomy, cholecystectomy, colectomy, or hernia repair. Outcomes were risk-adjusted with a multivariable logistic regression that accounted for patient characteristics (age, sex, comorbidities, admission type, and procedure performed) and hospital characteristics (teaching hospital status and nurse-to-patient ratio).

Results: This study included 3,404,911 beneficiary admissions for one of four operations at 890 CAH and 3,687 non-CAH hospitals. CAH beneficiaries were more likely to be white (95.9% vs. 86.0%, P<0.001) and less comorbid (64.8% vs. 76.5% with≥2 Elixhauser comorbidities, P<0.001). Mortality rates improved between 2010 and 2020 at critical access hospitals (6.9% to 4.7%, P<0.001) and non-critical access hospitals (7.3% to 5.3%, P<0.001) with no difference in rate of improvements between critical access hospitals and non-critical access hospitals (-0.2, 95% CI: -1.42-1.08), P=0.790). Serious complication rates improved between 2010 and 2020 at critical access hospitals (8.7% to 7.1%, P=0.030) and non-critical access hospitals (18.8% to 13.4%, P<0.001).

Conclusions: Over the last decade, surgical quality improvement at CAHs has kept pace with non-CAHs among Medicare beneficiaries with common surgical conditions. These data provide longitudinal evidence of the safety of surgical care at these rural facilities as policy makers continue making evidence-based decisions to preserve access and quality in these rural areas.

Keywords: critical access hospital; general surgery; quality; rural; rural surgery; small rural hospital; surgical quality.

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Conflict of interest statement

Financial disclosures and funding: Dr. Dimick is a cofounder of ArborMetrix, Inc, a company that makes software for profiling hospital quality and efficiency. The authors have no conflicts of interest pertaining to the work herein. Dr. Ibrahim receives funding from the Agency for Healthcare Research and Quality (AHRQ) as principal investigator on grant R01-HS028606-01A1, from AHRQ as a co-investigator on grant R18-HS028963, and from the National Institutes of Health (NIH) as a co-principal investigator on grant R0-1DK137466.

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