|
RESEARCH WEEKLY: Rural hospitals’ quality of care higher than in urban facilities
By Hope Parker
(June 7, 2023) Rural psychiatric facilities have a higher quality of care compared to facilities in urban areas, according to a nationwide study using data from 2015-2019. This study, published in “Psychiatric Services” in November 2022, also found that while many measures in care improved over this time period, rates of follow-up care after being discharged from a hospital decreased for both urban and rural hospitals. As more than 14.2 million Americans live with a serious mental illness, equal access to high-quality inpatient and follow-up care for anyone who needs it is a critical need nationwide.
Methods
This study analyzed data from the 2015-2019 Inpatient Psychiatric Facility Quality Reporting Program, American Hospital Association Annual Surveys, and American Community Survey zip code data sets. Data from hospitals in urban areas, hospitals in large rural areas, and hospitals in small or isolated rural areas were included.
Researchers examined several measures to determine quality of care, listed below:
Continuity-of-care measures included:
- Follow-up care with an outpatient provider within 7-days or 30 days.
- Appropriate justification for multiple antipsychotic medications at discharge.
- Timely and complete transmission of patient records to outpatient providers.
Patient experience measures included:
- Number of hours kept in physical restraint.
- Number of hours kept in seclusion.
Hospital characteristics included:
- For-profit or non-profit status.
- Hospital primary services (psychiatric or general medicine and surgery).
- System affiliation.
- Teaching status.
- Number of psychiatric beds.
- Accreditation by the Joint Commission or Det Norske Veritas.
- Critical access hospital status.
- Rural referral center status.
- Proportion of registered nurses among all hospital nurses.
Demographic data included:
- Age groups.
- Racial-ethnic composition.
- Rates of unemployment.
- Rates of insurance coverage.
- The number of households with broadband access
- The number of households below 200% of the federal poverty level
These variables were then analyzed using several statistical methods to determine differences in quality of care and outcome measures between urban, large rural, and small rural hospitals.
Key Findings
A total of 1,644 hospitals were included in this study. Urban facilities accounted for 76% of the sample, 16% were in large rural areas, and 8% were in small rural areas.
Urban hospitals were found to have more variation in quality of care than rural hospitals.
In comparison with urban hospitals, rural hospitals had higher rates of:
- Patients receiving 30-day and 7-day follow-up care with outpatient providers.
- Discharged patients receiving transition records with specified elements.
- Timely transition of records to outpatient service provider.
No differences between rural and urban facilities were found for rates of appropriate justification for patients discharged with multiple antipsychotic medications.
Over time, quality of care improved for both rural and urban hospitals. However, follow-up care rates decreased for all areas, with rates of follow-up care decreasing more rapidly in rural areas.
Rural hospitals also had lower rates of both physical restraint and seclusion. Because seclusion and restraint both have an increased risk of harm for both patients and staff, it is important to minimize its use as much as possible.
Hospital characteristics:
In comparison to urban facilities, rural facilities were:
- More likely to be general medicine and surgery hospitals, as opposed to specialized psychiatric facilities, and more likely to be publicly owned.
- Less likely to be accredited, teaching hospitals, to offer alcohol or drug dependency programs, and to be system-affiliated.
Demographic data:
In comparison to rural areas, urban areas had an older patient population. Rural areas had a higher proportion of patients who were non-Hispanic white as compared to urban areas. Rural areas also had higher levels of poverty, more uninsured individuals, and fewer households with broadband internet access.
Implications
Rural hospitals’ outperformance of urban hospitals may have several explanations. The first is that urban hospitals may be more likely to serve patients from outside of the area, making it more difficult to connect these patients to appropriate follow-up care and transition their records. The second potential explanation is that rural areas may be more collaborative, given that there are fewer mental health resources, so inpatient and outpatient facilities may have better relationships. The third potential explanation is that rural hospitals with fewer than 100 beds are eligible for reimbursement through the swing bed program. This is a reimbursement program that has been operating since 2002 and covers post-hospitalization extended care services. Even though this program does not cover psychiatric patients, participating rural hospitals are required to make detailed transition records, which likely improves hospital-wide transition coordination.
Detailed discharge information and coordination in particular is vital to the treatment of individuals with serious mental illness. Without communication between inpatient and outpatient facilities, follow-up care is more difficult for recently-discharged patients. Individuals who receive follow-up care after psychiatric hospitalization are less likely to be readmitted to the hospital and have lower rates of suicide. The decline in follow-up care during this time period suggests that it is necessary to further support these facilities in ensuring follow-up care is accessible for recently discharged patients.
| 
