Article Figures & Data
Tables
- Table 1.
Baseline Characteristics of Patients With Myocardial Infarction Admitted to Rural Hospitals or to Urban Hospitals
Admitted to Characteristic Rural Hospitals (n = 1,426) Urban Hospitals (n = 10,765) PValue Note: Excluding patients discharged or transferred to another acute care general hospital for inpatient care. APR-DRG = All Patient Refined Diagnosis-Related Group. Age, mean, years 82.4 68.9 <.001 Male, % 45.0 59.8 <.001 Black, % 0.14 1.13 <.001 Number of secondary diagnoses, mean 5.66 5.62 .45 Charlson Comorbidity Index, mean 0.96 0.69 <.001 APR-DRG risk index, mean 0.09 0.06 <.001 - Table 2.
Baseline Characteristics of Patients With Myocardial Infarction Staying in Rural Hospitals or Transferring Out of Rural Hospitals
Characteristic Stayed in Rural Hospitals (n = 1,426) Transferred Out of Rural Hospitals (n = 730) PValue APR-DRG = All Patient Refined Diagnosis-Related Group. Age, mean, years 82.4 71.5 <.001 Male, % 45.0 56.7 <.001 Black, % 0.14 0.14 .98 Number of secondary diagnoses, mean 5.66 4.24 <.001 Charlson Comorbidity Index, mean 0.96 0.67 <.001 APR-DRG risk index, mean 0.09 0.04 <.001 - Table 3.
Odds Ratios for In-Hospital Mortality Among Patients With Myocardial Infarction Admitted to Urban vs Rural Hospitals, Using Logistic Regression Models
Logistic Regression Model OR (95% CI) (Urban vs Rural Hospitals) PValue of the Hospital Variable cStatistic Note: Excluding patients discharged or transferred to another acute care general hospital for inpatient care. OR = odds ratio; CI = confidence interval; APR-DRG = All Patient Refined Diagnosis-Related Group. Unadjusted 0.42 (0.35–0.50) <.001 0.56 Adjusted for demographic characteristics (age, sex, race, admission type, payer) 0.70 (0.58–0.84) <.001 0.70 Adjusted for demographic characteristics and Charlson Comorbidity Index 0.73 (0.61–0.88) <.001 0.71 Adjusted for demographic characteristics and APR–DRG risk index 0.68 (0.56–0.82) <.001 0.86 - Table 4.
Baseline Characteristics Among Patients With Myocardial Infarction Grouped by Distance to the Nearest Urban Hospital
Distance to Nearest Urban Hospital Characteristic ≤ 14.08 Miles (n = 6,097) >14.08 Miles (n = 6,104) PValue Note: Excluding patients discharged or transferred to another acute care general hospital for inpatient care. APR-DRG = All Patient Refined Diagnosis-Related Group. Distance to the nearest urban hospital, mean, miles 4.94 34.20 <.001 Admitted to urban hospitals, % 99.54 77.09 <.001 Age, mean, y 68.89 72.02 <.001 Male, % 58.65 57.45 .18 Black, % 1.95 0.08 <.001 Number of secondary diagnoses, mean 5.72 5.53 <.001 Charlson Comorbidity Index, mean 0.72 0.72 .67 APR-DRG risk index, mean 0.07 0.07 .48 Length of stay, d 5.34 5.30 .70 In-hospital mortality rate, % 7.07 7.52 .34 - Table 5.
Instrumental Variable Estimates of the Difference of In-Patient Mortality Between Urban and Rural Hospitals
Tests for Instrumental Variables IV Estimates of Hospital Type (Urban vs Rural) Instrumental Variable Model Number of Groups for Instrumental Variable Instrument F Statistic* PValue for Overidentifying Restrictions Tests† Coefficient β PValue IV = instrumental variable; APR-DRG = All Patient Refined Diagnosis-Related Group. * If an F statistic is less than 10, the instrumental variables are weak, given that instrumental variables have small partial correlation with the variable of interest. † If P <.05, one of the instrumental variables correlated with unmeasured confounders. Unadjusted 2 1,540.16 – −0.02 .34 4 642.65 .65 −0.03 .16 8 294.02 .20 −0.03 .14 12 184.31 .13 −0.03 .13 Adjusted for demographic characteristics (age, sex, race, admission type, payer) 2 1,568.24 – 0.013 .58 4 652.86 .80 0.0081 .69 8 289.74 .22 0.0084 .68 12 187.14 .10 0.0065 .75 Adjusted for demographic characteristics and Charlson Comorbidity Index 2 1,539.90 – 0.0090 .69 4 642.51 .92 0.0053 .80 8 289.72 .25 0.0060 .77 12 184.29 .12 0.0040 .84 Adjusted for demographic characteristics and APR-DRG risk index 2 1,694.27 – −0.0034 .87 4 640.61 .92 −0.0069 .72 8 318.20 .17 −0.0032 .87 12 202.50 .01 −0.0063 .74
Additional Files
The Article in Brief
Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care
Paul A. James, MD, and colleagues
Background Previous research suggests that rural hospitals give lower quality of care to patients with heart attack (myocardial infarction) than hospitals in urban areas. This study uses unique methods to examine whether patient characteristics (such as age and health) affect rates of death for heart attack patients in rural vs urban hospitals.
What This Study Found Death rates from heart attack were not higher in rural hospitals when patient characteristics were taken into account. Heart attack patients in urban and rural hospitals were significantly different from each other. Patients admitted to urban hospitals were younger and more likely to be male or black, whereas those admitted to rural hospitals were sicker and older than their urban counterparts.
Implications
- In-hospital death rates that do not consider the severity of patient illness may not accurately indicate quality of care of heart attack patients.
- These findings challenge the suggestion that heart attack patients receive worse care in rural hospitals compared with urban hospitals.
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