Researchers at Harvard Medical School did the first US nationwide study of hospitals with no more than 25 acute care beds. It's estimated that a quarter of the hospitals in the US fit that category. The researchers analyzed the records of close to 2.4 million patients admitted to nearly 5,000 hospitals with a diagnosis of heart attack, heart failure or pneumonia from 2008 to 2009. Depending on the condition, compared to large, urban hospitals, patients admitted to small rural hospitals were between 30% and 70% more likely to die within 30 days of the date of admission. The researchers weren't surprised that outcomes at rural hospitals were worse - but were surprised by the magnitude of the difference. The study was published July 6 in the Journal of the American Medical Association.
As part of the study, the researchers uncovered several factors that contributed to poorer results. Small hospitals included in the study were far less likely to have a heart or chest specialist on staff. They were less likely to have intensive care units, and to perform angioplasty to unblock coronary arteries. They were also less likely than other hospitals to have electronic health records. All of those factors contributed to the fact that these small hospitals delivered care that was of significantly lower quality than that delivered at larger hospitals.
We don't have a Canadian study as comprehensive as this one. However, I think the results are relevant to the situation here. According to a report prepared by the Society of Rural Physicians of Canada, one in five Canadians lives in rural areas. Rural Canadians tend to be sicker and have a shorter life expectancy than people who live in cities. Despite that, far fewer doctors practice in rural Canada than in urban settings. Only 3% of Canadian specialists practice in rural areas. People with heart attacks and heart failure often have to be transferred to hospitals away from home, a factor that increases the chance of dying. Women with high risk pregnancies often have to move away from home to have their babies in hospitals equipped with a neonatal intensive care unit. That increases the cost of care and contributes to poor medical outcomes.
It's tempting to shutter smaller hospitals that aren't up to snuff. In general, hospitals that treat a critical mass of patients have better outcomes than those that provide care to a more sporadic patient population. That's true for everything from heart bypass to hip replacements to babies delivered. It also makes economic sense for the provinces to close down smaller hospitals. The trouble is, the government still has an obligation to provide a basic level of care for people who live in rural areas or transport them efficiently to larger hospitals when they need it.
Politically, closing down a hospital is a losing proposition. And, when a patient dies en route to a hospital in the next town, as has happened in Ontario fairly recently, some will say the patient would have lived had the local ER or hospital not been closed down.
The short term fix is for smaller hospitals to enter into agreements with larger ones to share technology, facilities, specialists and other hospital personnel, and best practices. To make that work, you have to provide financial incentives to larger hospitals to share resources. Telemedicine can help facilitate contact between urban and rural hospitals. Although this study didn't prove it, it's possible that electronic health records that can be shared between larger and smaller hospitals can help as well.
The long term fix is to provide greater health care resources to all patients - regardless of where they live. For instance, the Czech Republic and Denmark have dramatically reduced the time it takes for patients to receive angioplasty by increasing the number of specialists who can do the procedure and by deploying them evenly throughout the country.
To do that in Canada, one requires planning and a long time horizon. Hard to do that when you're constantly facing re-election.