Intensive care in critical access hospitals: a demographic and outcome evaluation

Intensive care in critical access hospitals: a demographic and outcome evaluation Tariro Mupombwa SUMR Mentor: Jeremy Kahn, MD MS August 8, 2008

Overview • The state of US critical care • Critical access hospitals • Intensive care in critical access hospitals • Future directions

What is critical illness? • Difficult to define • High risk of death • Admission to an ICU • Anyone requiring a intensive monitoring • Is a syndrome and not a disease • Can happen anywhere and at any time

The current state of critical care • 5.6 million adult ICU admissions annually • Mean ICU admissions per life: 1.7 • 15% mortality • 600,000 hospital deaths (1/5 of US) • $67 billion per year • 0.56 to 0.67% of GDP Kersten CCM 2004 Angus CCM 2004

Critical care in small hospitals is associated with a higher risk of death Kahn NEJM 2006

What are critical access hospitals (CAHs)? • Small rural hospitals • Designated by Medicare and States • Cost-based reimbursement • Should provide 24 hour intensive and emergency services • Typically • Less than 25 inpatient beds • Average LOS of 96hrs or less CMS CAH fact sheet 2007

The scope and scale of intensive care services in CAHs is unknown • Research objectives: • Determine number of patients receiving intensive care in critical access hospitals • Compare demographics and outcomes to other hospitals

Intensive care in critical access hospitals • 2004-2006 Pennsylvania state discharge database • CAHs identified by Medicare cost reports • Critical illness identified by resource utilization codes • Diagnoses and procedures identified by ICD-9 code • 30-day mortality: linkage to DOH death index

Intensive care No intensive care 12 hospitals in PA certified as CAH

CAH characteristics

Admission characteristics

Admission characteristics cont…

Transfers were relatively uncommon • 16% of patients were transferred to another hospital at some point • 5% of patients transferred directly to a referral hospital ICU • Median transfer distance = 31 miles [interquartile range: 17 – 38]

What about rural hospitals that aren’t CAHs? • Valid comparisons are difficult • We identified 7 similar non-CAH designated hospitals • Less than 50 beds • Rural hospitals by 2000 US Census • 3,548 patients

Conclusions • Intensive care in CAHs represents a small but important part of all intensive care • ICU patients in CAHs tend to be less sick than those in other hospitals • CAHs transfer a minority of their ICU patients • Patients in similar rural hospitals are sicker with a higher risk of death (with a caveat)

Limitations • Single state (PA) • Critical care defined by resource utilization codes rather than clinical condition • Different severity measures frequently produce different impressions about hospital performance

Policy Implications • CAHs represent an important target for improving quality of care of ICU patients • Policy interventions such as regionalization and state-wide quality improvement efforts should be considered

Future directions • To determine the economic outcomes of critical care in CAHs in relation to similar rural hospitals • Look at organizational characteristics of ICUs within CAHs

Special thanks to the following organizations for their generous support: • The University of Pennsylvania Provost’s Diversity Fund • The Center for Health Equity Research and Promotion (CHERP) • Pennsylvania Department of HealthOffice of Health Equity

Acknowledgements • Jeremy Kahn, MD MS • Jason Lott, MA • Joanne Levy, MBA MCP • SUMR scholars • Leonard Davis Institute

Intensive care in critical access hospitals: a demographic and outcome evaluation