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Editor’s Spotlight/Take 5: What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?

Manner, Paul A. MD, FRCSC

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Clinical Orthopaedics and Related Research: January 2021 - Volume 479 - Issue 1 - p 4-8
doi: 10.1097/CORR.0000000000001591

While much research and commentary has focused on healthcare disparities involving race and poverty [7, 8, 13], less has been written about how geography impacts health. Why is this? Well, people studying the problem, media companies and institutions with clout, are generally located in big cities, and so it’s easy for researchers and their institutions to focus on what they see in front of them.

But many United States citizens—almost 60 million of them—live rurally. And if we’re talking lack of healthcare equity, this is a great place to start. There are 3142 counties (or their administrative equivalent) in the United States—and the majority are rural to a greater or lesser degree [4]. The worst for life expectancy? Oglala-Lakota, SD, where males can expect to live less than 63 years and females less than 71—a full 14 and 11 years less than the average in the United States, respectively [4]. Worst for blood pressure? Holmes County, MS, where 58% of the population has hypertension [4]. About 26% of residents in Starr County, TX have diabetes [4], 59% of Issaquena County, MS residents have obesity [4], 36% of those in Menominee County, WI report binge drinking … and so on [4]. These locales, and others like them, have a three-fold higher risk of mortality than the United States at large for any and every age group [4]. By any measure, this is grim—we have a lot of people with profound health problems, who don’t have ready access to care.

The question of how to address these disparities has vexed healthcare officials in the United States for generations. Some history helps to set the stage. The Hill-Burton Act, passed in 1946, was part of a post-war effort at improving the health and health care of Americans and provided funds to increase the number of hospital beds across the country [12]. Facilities that received funding were required to provide a “reasonable volume” of free care each year to the poor while states and localities were required to insure economic viability of the new hospitals. This was a problem. “Reasonable volume” went undefined, and truly poor locales could not afford to build hospitals, even with federal funding. Equity in health care in rural areas thus remained an unmet goal.

In 1997, the Federal government established the Critical Access Hospital (CAH) program, with the goal of supporting small hospitals in rural areas to serve residents who would otherwise be a long distance from emergency care. To receive federal funding, CAHs may have no more than 25 beds and must have an average duration of hospital stay under 96 hours. They must also be more than 35 miles from another hospital, with exceptions allowed for areas with poor roads or difficult terrain. Critical access hospitals must have all the equipment and medications required for essential medical treatment and have agreements in place with larger hospitals for the transport of patients in need of further care. They must offer 24/7 emergency care and have a physician on-call available to be on-site within 60 minutes. To address personnel concerns, CAHs are allowed some flexibility in staffing, particularly in remote locations. As of January 2018, there are 1343 certified CAHs in 45 states; Connecticut, Delaware, Maryland, New Jersey, and Rhode Island (being small and urban states) do not have any CAHs [2].

Even so, rural hospitals face perennial challenges, including low patient volumes, an unfavorable payer mix, patients who often present with profound health issues, geographic isolation, workforce shortages, aging infrastructure, and limited access to external resources. With this in mind, I’d expect them to fall short of bigger, urban hospitals.

As it happens, they don’t. Carmen E. Quatman MD and her group from the Ohio State University in Columbus, OH, USA, build on a growing body of data showing that rural hospitals are meeting and (sometimes exceeding) the level of care provided by their city slicker cousins [10]. While earlier studies showed that CAHs had fewer clinical capabilities, worse measured processes of care, and higher mortality rates for patients with acute myocardial infarction, congestive heart failure, or pneumonia than non-CAH hospitals [5, 6], more recent studies focusing on common surgical problems show that small rural hospitals can provide safe and cost-effective care [1, 3, 5, 6, 11].

In this month’s Editorial Spotlight paper [10], we take a good look at the quality of care afforded to patients with hip fractures in the CAH setting. Hip fractures are common injuries, occurring in patients who are typically older and often in poor health. As the authors note, surgical treatment within 48 hours, with minimal delays in care, is associated with improved outcomes, but the quality of care following surgery is just as important. Rural providers face unique challenges, often overlooked when “big” policy decisions are discussed. Patients, the public, and policymakers need to know whether they can count on the small hospitals that serve rural communities and what resources might help those hospitals.

Join me in the Take 5 interview that follows with Carmen Quatman MD, senior author of “What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?”.

Take 5 Interview with Carmen E. Quatman MD, senior author of “What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?”

Paul A. Manner MD:A recurrent challenge faced by rural hospitals is the difficulty in recruiting physicians and other providers. Is there a perception that rural hospitals are not practicing high-quality medicine? How might your findings affect the willingness of providers to work in a rural setting, and what might rural hospitals do as a consequence?

Carmen E. Quatman MD

Carmen E. Quatman MD: I think since we are increasingly seeing more subspecialization and even sub-subspecialization of orthopaedic surgeons, it is hard for hospitals to maintain a practice with the number of subspecialty type of patients that they may desire. Practicing in a rural setting may necessitate surgeons remain skilled and current on trauma needs, even if this is not their specialty. Although all of us are trained in orthopaedic trauma, we are not necessarily trained for the complexity of care that some patients with hip fracture may need. It is common to see patients with transplant histories, major cardiac histories, or ongoing cancer treatments. It makes it more difficult to feel comfortable treating these patient populations because often their bone quality and risk for perioperative complications may necessitate medical specialists for help with perioperative care needs. I think patients with hip fractures can be treated well at CAHs. However, it is important that surgeons realize early in the episode of care which patients may need transfer to higher acuity hospitals. It should be a goal to make the transfer happen as quickly and seamlessly as possible—any delay in the transfer process could impede the patient’s care and possible outcome. It is important that this is established early, because delay in transfer for even 4 or 5 hours can lead to a 24- to 48-hour delay in surgical care. Patients are often made nil per os, and once they arrive at the new hospital, the medical workup starts over. A patient can go a day or two without receiving surgery, or food, or mobilization, even though the best intent was to help the patient receive quality care.

What is difficult to account for in our study is patients with the most complex medical needs. Even at our hospital, which is a Level I trauma center, with on-site safety net heart and cancer hospitals, we have difficulty getting certain patients to the building safely. If they have pulmonary hypertension or require cardiac anesthesia, the timing of coordinating the team can be difficult. I can’t imagine trying to do this in a rural setting.

Perhaps the best thing we can do is establish triaging protocols to understand earlier which patients need transfer to higher acuity hospitals and put mechanisms in place to make these transfers occur expeditiously, safely, and with high levels of communication between orthopaedic providers to avoid redundancy in care. With this type of process, recruitment of orthopaedic surgeons to rural areas or CAHs may help alleviate surgeon worries about not having the appropriate ancillary services for more complex patients and avoiding more serious complications. At the same time, it would allow for these types of hospitals to participate in bundled payment options and improve efficiency, time to operating room, length of stay and other quality needs.

Dr. Manner:Another challenge for rural providers is that their patients are often older, sicker, and have less support than patients in cities or suburbs. Are rural providers “cherry-picking” by keeping the patients with less complex problems, and “lemon-dropping” by sending the patients with more difficult problems on to referral centers?

Dr. Quatman: I am sure this happens, though I don’t know how often. Here in Ohio, I’ve sometimes seen a variation on this theme, wherein providers admit a patient, treat him or her for a few days, and then transfer that patient after a complication occurs or when he or she is deemed too sick. It’s more of a delayed “cherry-picking/lemon dropping,” but it has the same harmful effect—cost-shifting to safety-net hospitals (which may or may not be able to bear the costs over the longer run), and certainly inconvenience and fragmented care for the patient. Many patients with hip fractures are in serious medical decline, which often leads to falls. Some of these patients may not have seen a physician for years. It’s hard to know by just seeing a “hip fracture” on a radiograph whether a patient has serious medical complexities that may not be best addressed in a rural, small community hospital. Just because a surgeon is comfortable treating a fracture, does not mean the other medical team members involved (anesthesia, medical specialists, cardiology, intensive care unit) feel comfortable supporting the patient within the entire episode of care. Ideally, all patients could be treated at the hospital they initial visit for care. But in reality, the first hospital may not be the best setting. It would be better if we can identify as early as possible which patients have more complex care needs and get them the right care, in the right place, at the right time.

I also think it is critical that the healthcare system determine how to appropriately reimburse hospitals based on our patients’ medical complexities. There is quite a spectrum of needs for hip fractures and just because the radiographs may be similar and the implant used may be similar for the fracture surgery, the continuum of care may need to look different to achieve similar outcomes. Reimbursing hip fracture surgeries based on DRG alone at hospitals impedes the ability to account for the fact that not all the needs of a patient with hip fracture are generalizable. We were reluctant to perform this study because there is no way to truly account for our patients’ complexities and showing that CAHs may in fact be unintentionally “cherry picking”. We may not be doing a true comparison by using just coding and billing data. However, until we start to create dialogue and understanding the entire patient encounter and a deeper understanding of the types of patients treated at the different facilities where resources may be vastly different, we are not helping improve quality of patient care across all care domains. It may be that bundled care looks very different for the more-complex patients, but it might still be possible. Instead, we need to stop trying to compare apples and oranges and better risk stratify as early as possible and make sure patients get the best care possible at the sites that are most appropriate for their complexity of needs.

Dr. Manner:Following up, how would you view the concept of the high-powered, high-cost tertiary care center as the site of definitive care? How should we decide who goes where?

Dr. Quatman: I believe that the surgery itself should be the top determining factor in deciding where a patient should receive care. It is a 2- to 3-hour “intraoperative” process, whereas the majority of the needs in recovery for patients take place outside of the operating room and specifically outside the hospital. With the average length of stay in the hospital between 4 and 6 days, the majority of complications that occur within 90 days will happen outside the hospital environment [9]. Focused efforts to understand the most important quality metrics and outcomes related to care outside the intraoperative environment are paramount. More specifically, we need to understand and improve the entire 90-day clinical episode. What if the patient’s home environment is high-risk for future falls? If a hospital can’t help facilitate the other comorbidity, complex needs of the patient, or help with safe transitions of care, then they probably should not be doing the surgery.

Having geriatrics, palliative, and even hospice care access may be just as important as the appropriate surgical team, particularly for this high-risk hip fracture population whose mortality is up to 25% in the first postoperative year. Having a robust approach to nutrition, mobility, and delirium and fall prevention may be some of the most important things we focus on for patients with hip fractures. If hospitals don’t appropriately resource these parts of the care, it does not matter how talented or resourced the intraoperative or hospital environment is, patients will not receive the highest quality of care throughout their recovery.

Dr. Manner:Safety net hospitals are typically in urban environments but seem to have a lot in common with CAHs. Specifically, they face the conundrum of patients with a host of nonmedical problems but not a lot of resources. What are the unique challenges for rural critical access hospitals that urban hospitals don’t have?

Dr. Quatman: Probably the most challenging thing for rural environments are the resources external to the hospital. In urban environments, there are a number of skilled nursing care facilities to choose from, whereas there may only be one in a rural setting if any. With nearly 80% or more of hip fractures requiring postacute care settings at discharge, the “choice” of care is not decided on the basis of quality metrics as much as medical care needs. In addition, in urban settings, there are unique “ride share” and food service options that may make it possible for older, vulnerable adults to still receive food/nutrition services and transport to not only their orthopaedic postoperative needs but other medical care needs to avoid complications in the 90-day window. Aging resources in urban settings are often also more robust with resources such as meals on wheels, medical transport, access for making homes safe (grab bars, ramps), and now there are urban areas that have community paramedicine programs that will do home checks on patients recently discharged from hospitals. In rural environments, these services may not play a role in the hospital environment, and the overall outcome of the patient transition back to the home environment may look very different.

Dr. Manner:Perhaps I’m cynical, but I find that a lot of “quality improvement” initiatives focus on process and documentation, and that my ability to score well depends on my level of enthusiasm for filling out forms and clicking a mouse. Is this a question of rural hospitals not having the resources to check boxes correctly, rather than being a true lack of good care? And if so, what should policymakers do about it?

Dr. Quatman: I don’t think you are cynical at all. I think “quality improvement” metrics can be misleading. Protocols can be helpful to improve processes, but when you group people together that shouldn’t be grouped together as a way to “evaluate” and improve, there are missed opportunities to make impactful change. For example, extracting data by diagnosis-related group (DRG) with an arthroplasty code is common practice for hospitals to evaluate orthopaedic quality. If done without qualifiers, you will get all patients, including hip fracture patients with arthroplasty. Without physician champions to clarify why this is problematic, you will have a misleading picture of your overall care. A 30-day patient mortality for a hip fracture arthroplasty is not uncommon, and over the course of the year, could dramatically impact “arthroplasty” mortality reported to your hospital leadership.

Still, I think we can all agree that an elective total hip is different than an urgent total hip performed in an elderly patient with a fall. Checking a box and documenting may work well for an elective surgery, but in a fracture nonelective situation, those same check boxes may have little overall impact on outcome and quality improvement. Even more so, if you are looking to send most patients home after arthroplasty, but the majority of your arthroplasty patients underwent revisions or had hip fractures, you will definitely miss the mark. Sometimes “coding” extraction is more misleading than our previous ways of doing systematic chart reviews


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