05/09/2019
Austin Frakt[H]ospital closures in rural areas are both a source of concern and a perplexing challenge. Where populations are thin and in the context of changing patterns of care—shifting away from hospitals—what can be done to maintain adequate health care infrastructure for the most critical and urgent conditions?
Go read my recent JAMA Forum post for more. (Research for it was supported by the Laura and John Arnold Foundation.)
11/08/2017 Austin FraktKaty Kozhimannil was kind enough to let me collaborate on a Washington Post op-ed that published today. It’s on a topic in her area of expertise — prenatal and maternity care in rural America. Here’s one passage:
A wave of rural obstetric unit closures has increased the distance to maternity and delivery services; the least populated and most remote communities have been hit hardest. What’s left are maternity-care deserts in some of the United States’ most vulnerable communities. […]
The generosity (or lack thereof) of a state’s Medicaid program also contributes to maternity deserts. Medicaid pays for more than half of the births at rural hospitals. Rural communities in states where Medicaid covers only the poorest pregnant women are less likely to have in-county obstetric services, compared with states with more generous eligibility criteria.
Beyond Medicaid expansion, there’s more we can do, as we describe. Read the rest.
07/07/2011 Don TaylorYesterday I posted on a JAMA study that showed that critical access rural hospitals (CAHs) have higher adjusted mortality for 3 common conditions. 30 day mortality for patients admitted for AMI, CHF and pneumonia remained higher in CAHs even after controlling for fewer resources (less likely to have an ICU, cardiac cath lab, Electronic Health Records), reduced clinical personnel, membership in a hospital or health care system, and degree of rurality.
The authors note that they were unable to control for patient health behaviors that are known to be higher/worse in rural areas (obesity, smoking, exercise). Further, in the Medicare program, patients have absolute choice of what hospital they use for health care services, and there are always worries about patient selection effects (patient choices being related to mortality in ways that are not obvious). Of course in the case of emergencies (AMI is one of the conditions studied) choice may be irrelevant. Do these unmeasured individual variables explain the observed mortality differences?
Typically when you have an observational study and concerns that unmeasured indivdiual variables could explain the differences in observed outcomes, the holy grail is a randomized control trial (RCT) to determine whether outcomes and quality are truly worse in CAHs. However, in this case, I don’t think a RCT could really provide a meaningful answer (which is good news, because you could never do the trial). The reason is that people don’t live in clinical trials. Some of them live in rural areas–about 60 Million Americans. They choose to live there and we have to have a health care system that works for such citizens.
There are two types of questions that need to be addressed to inform policy:
06/08/2011 Austin FraktAct one of this week’s This American Life is a horrific tale of a doctor, among other things, gone bad in a rural Texas hospital.
In a small west Texas town called Kermit, two nurses were accused of harassment after they complained to the medical board that a doctor was putting patients in danger. The nurses were fired and then arrested, facing ten years in prison. Reporter Saul Elbein found that a group of powerful men in Kermit went to extreme and sometimes ridiculous lengths to try to bring down these nurses.
The story reveals, among other things, the challenges of getting high quality doctors to practice in some rural areas.
