Factors Associated with Remote Patient Monitoring Services Provision by Hospitals and Health Care Systems in the United States.

Purpose: To assess the factors associated with offering remote patient monitoring (RPM) services. Methods: We integrated three datasets: (1) 2019-2020 Area Health Resource Files, (2) 2019 American Community Survey, and (3) 2019 American Hospitals Association annual survey using county Federal Information Processing Standards code to evaluate associations between hospital characteristics and county-level demographic factors with provision of (1) post-discharge, (2) chronic care, (3) other RPM services, and (4) any of these three RPM service categories. These outcomes were analyzed using multi-level, mixed-effects multivariate logistic regression modeling to account for county-level clustering of hospitals. Findings: Among 3,381 hospitals, 1,354 (40.0%) provided any RPM services. Being part of a clinically integrated network (CIN) and private, non-profit (vs. public) ownership were respectively associated with 104.5% (95% confidence interval [CI]: 69.4-146.8%; p < 0.001) and 30.4% (95% CI: 2.5-66.0%; p = 0.031) higher odds of providing any RPM services. Critical access hospital (CAH) designation, for-profit (vs. public) ownership, and location in the South (vs. Northeast) were associated with significantly lowering odds of providing any RPM services by 36.2% (95% CI: 14.2-52.6%; p = 0.003), 70.1% (95% CI: 56.0-79.6%; p < 0.001), and 34.0% (95% CI: 2.8-55.1%; p = 0.035), respectively. Similar trends were found with the various RPM service categories. Conclusions: The factors most associated with provision of any RPM services were hospital-level factors. Specifically, being part of a CIN and private, non-profit ownership had the highest positive associations with offering RPM services whereas location in the South and CAH designation had the strongest negative associations. Further studies are needed to understand the reasons behind these associations.

Telehealth Decreases Rural Emergency Department Wait Times for Behavioral Health Patients in a Group of Critical Access Hospitals.

Background: Telehealth has been proposed as an important care delivery strategy to increase access to behavioral health care, especially in rural and medically-underserved settings where mental health care provider shortage areas predominate, to speed access to behavioral health care, and reduce health disparities.Introduction: This study was conducted to determine the effects of telehealth-based care delivery on clinical, temporal, and cost outcomes for behavioral health patients in rural emergency departments (EDs) of four Midwestern critical access hospitals (CAHs).Materials and Methods: Observational matched cohort study of adult (age ≥18 years) behavioral health patients treated in participating CAH EDs from 2015 to 2017 (N = 287). Telehealth cases were matched 2:1 retrospectively to nontelehealth control cases based on gender, age ±10 years, diagnosis group, and CAH, before implementation of telehealth in the rural hospitals (2005-2013; N = 153).Results: The greatest number of behavioral health cases evaluated was in the mood, anxiety, and other mental health disorders category. The majority of patients in the telehealth (74%) and nontelehealth (68%) cohorts were 18-44 years. Mean ED wait time for the telehealth cohort was significantly shorter at 12 min (95% CI 11-14 min) (p < 0.001) compared to a mean time of 27 min (95% CI 22-32 min) for the nontelehealth case controls (local provider only). The ED length of stay (LOS) for the telehealth cohort was significantly longer (M = 318 min vs. 147 min, p < 0.001) compared to the nontelehealth cohort. The end of telehealth visit to departure (EOTVtD) from the ED in minutes was evaluated to highlight factors potentially influencing delivery of behavioral health care in the ED. Across three behavioral diagnostic categories, time in minutes from end of telehealth visit to disposition/discharge was significantly longer for suicide and intentional self-injury cases (n = 100; 113 min, 95% CI 88-145; p = 0.004) compared to anxiety, mood, and other mental health disorders (n = 126; 66 min, 95% CI 52-83). There was a clinically meaningful difference in EOTVtD in minutes for substance abuse-related cases, which were shorter in length on average (n = 58; 71 min, 95% CI 54-94). Total ED costs for substance abuse-related cases for the telehealth (n = 58; $4556, 95% CI $3963-$5238) cohort were significantly higher than for the two other behavioral diagnostic groups (p < 0.001).Conclusions: Telehealth consultation in the ED for behavioral health cases was associated with decreased wait time and longer ED LOS. Similar to recent studies, the most common behavioral health cases involved mood and anxiety disorders. Costs related to treatment were highest for substance abuse-related cases, likely due to the additional interventions needed, especially related to resuscitation There are opportunities to improve ED efficiencies and post-telehealth visit protocols related to the timeframe extending from the EOTVtD from the ED, which continues to be a focus of future research. Additional research is also needed to determine if telehealth lends itself more effectively to specific categories of behavioral health cases.

Trialing the Community-Based Collaborative Action Research Framework: Supporting Rural Health Through a Community Health Needs Assessment.

PURPOSE: To describe the application of the Community-Based Collaborative Action Research (CBCAR) framework to uplift rural community voices while conducting a community health needs assessment (CHNA) by formulating a partnership between a critical access hospital, public health agency, school of nursing, and community members to improve societal health of this rural community. METHOD: This prospective explorative study used the CBCAR framework in the design, collection, and analysis of the data. The framework phases include: Partnership, dialogue, pattern recognition, dialogue on meaning of pattern, insight into action, and reflecting on evolving pattern. DISCUSSION: Hospital and public health agency leaders learned how to use the CBCAR framework when conducting a CHNA to meet Affordable Care Act federal requirements. Closing the community engagement gap helped ensure all voices were heard, maximized intellectual capital, synergized efforts, improved communication by establishing trust, aligned resources with initiatives, and diminished power struggles regarding rural health. CONCLUSION: The CBCAR framework facilitated community engagement and promoted critical dialogue where community voices were heard. A sustainable community-based collaborative was formed. The project increased the critical access hospital's capacity to conduct a CHNA. The collaborative's decision-making capacity was challenged and ultimately strengthened as efforts continue to be made to address rural health.

A decade of health assessments in Appalachia.

Purpose The purpose of this paper is to describe standardized clinical process of care and quality performance metrics at Roane Medical Center (RMC) and compare data from 2005 to 2015. Design/methodology/approach Information was extracted from a nationwide sample of short-term acute care hospitals using the Hospital Quality Alliance (HQA) database, evaluating multiple parameters measured at RMC. HQA data from RMC were matched against state and national benchmarks; findings were also compared with similar reports from the same facility in 2005. Findings Information collected by HQA expanded substantially in ten years and queried different parameters over time, thus exact comparisons between 2005 and 2015 cannot be easily calculated. Nevertheless, analysis of process of care data for 2015 placed RMC at or above state- and national-average performance in 64.9 percent (24 of 37) and 56.5 percent (26 of 46) categories, respectively. RMC registered superior process of care scores in heart failure care, pneumonia care, thrombus prevention and care, as well as stroke care. While RMC continues to perform favorably against state and national reference groups, the differences between RMC vs state and RMC vs national averages using current reporting metrics were both statistically smaller in 2015 compared to 2005 ( p<0.05). Research limitations/implications Perhaps the most significant interval health event for the RMC service area since 2005 was a coal ash spill at the nearby Tennessee Valley Authority facility in December 2008. Although reports on environmental and health effects following one of the largest domestic industrial toxin releases reached a number of important conclusions, the consequences for RMC in terms of potential added clinical burden on emergency services and impact on chronic health conditions have not been specifically studied. This could explain data reported on emergency department services at RMC but additional research will be needed to establish causality. Practical implications While tracking of care processes at all US hospitals will be facilitated by refinements in HQA tools, longitudinal evaluations for any specific unit will be more meaningful if the assessment instrument undergoes limited change over time. Social implications Appalachia remains one of several regions in the USA often identified as medically underserved. Hospitals here have confronted the challenge of diminished reimbursement, high expenses, limited staffing and other financial hardships in a variety of ways. Since the last published report on RMC, a particularly severe global recession has placed additional stress on organizations offering crucial health services in the region. Originality/value As a follow-up study to track potential changes which have been registered in the decade 2005-2015, this is the first report to provide original, longitudinal analysis on RMC, an institution operating in a rural and underserved area.

Exploring COVID-19 census burdens by US hospital characteristics: Implications of quality reporting at rural and critical access hospitals.

PURPOSE: By assessing longitudinal associations between COVID-19 census burdens and hospital characteristics, such as bed size and critical access status, we can explore whether pandemic-era hospital quality benchmarking requires risk-adjustment or stratification for hospital-level characteristics. METHODS: We used hospital-level data from the US Department of Health and Human Services including weekly total hospital and COVID-19 censuses from August 2020 to August 2023 and the 2021 American Hospital Association survey. We calculated weekly percentages of total adult hospital beds containing COVID-19 patients. We then calculated the number of weeks each hospital spent at Extreme (≥20% of beds occupied by COVID-19 patients), High (10%-19%), Moderate (5%-9%), and Low (<5%) COVID-19 stress. We assessed longitudinal hospital-level COVID-19 stress, stratified by 15 hospital characteristics including joint commission accreditation, bed size, teaching status, critical access hospital status, and core-based statistical area (CBSA) rurality. FINDINGS: Among n = 2582 US hospitals, the median(IQR) weekly percentage of hospital capacity occupied by COVID-19 patients was 6.7%(3.6%-13.0%). 80,268/213,383 (38%) hospital-weeks experienced Low COVID-19 census stress, 28% Moderate stress, 22% High stress, and 12% Extreme stress. COVID-19 census burdens were similar across most hospital characteristics, but were significantly greater for critical access hospitals. CONCLUSIONS: US hospitals experienced similar COVID-19 census burdens across multiple institutional characteristics. Evidence-based inclusion of pandemic-era outcomes in hospital quality reporting may not require significant hospital-level risk-adjustment or stratification, with the exception of rural or critical access hospitals, which experienced differentially greater COVID-19 census burdens and may merit hospital-level risk-adjustment considerations.

Rural Trauma Team Development Course Positively Impacts its Desired Objectives.

BACKGROUND: The Rural Trauma Team Development Course (RTTDC) is designed to help rural hospitals better organize and manage trauma patients with limited resources. Although RTTDC is well-established, limited literature exists regarding improvement in the overall objectives for which the course was designed. The aim of this study was to analyze the goals of RTTDC, hypothesizing improvements in course objectives after course completion. METHODS: This was a prospective, observational study from 2015 through 2021. All hospitals completing the RTTDC led by our Level 1, academic trauma hospital were included. Our institutional database was queried for individual patient data. Cohorts were delineated before and after RTTDC was provided to the rural hospital. Basic demographics were obtained. Outcomes of interest included: Emergency Department (ED) dwell time, decision time to transfer, number of total images/computed tomography scans obtained, and mortality. Chi square and non-parametric median test were used. Significance was set at P < .05. RESULTS: Sixteen rural hospitals were included with a total of 472 patients transferred (240 before and 232 after). Patient demographics were similar before and after RTTDC. ED dwell time was significantly reduced by 64 min (P = .003) and decision to transfer time was cut by 62 min (P = .004) after RTTDC. Mean total radiographic images and CT scans were significantly reduced (P < .001 and P = .002, respectively) after RTTDC. Mortality was unaffected by RTTDC completion (P = .941). CONCLUSION: The RTTDC demonstrates decreased ED dwell time, decision time to transfer, and number of radiographic images obtained prior to transfer. More rural hospitals should be offered this course.

"We Have Outgrown Our Space; Our Facility Is Old and Falling Apart": Physical Design Implications to Address the Needs and Priorities of a Critical Access Hospital (CAH).

OBJECTIVE: This exploratory study examines a rural critical access hospital (CAH) staff's perception of current obstacles and needs concerning the physical environment. BACKGROUND: CAH intends to improve access to healthcare, coordinate with experts and providers, and serve as the rural population's healthcare hub. It is imperative to understand environmental qualities that impact the quality of care to develop effective policies and design guidelines for rural healthcare. Nevertheless, a limited number of studies have focused on user or organizational outcomes related to the physical environment of rural healthcare settings. METHODS: This cross-sectional exploratory qualitative case study was conducted as part of the facility planning process for a CAH in rural North Carolina. Hospital staff participated in a survey exploring their satisfaction with the overall physical environment privacy, space allocation, and department adjacency. An open-ended question asked staff to elaborate on needed improvements and changes in their department. RESULTS: Findings show low satisfaction levels for space allocations for emergency department, lab, surgery, and wound care. Safety and quality were the two emerging outcomes of the physical environment's shortcomings. Two clusters emerged from the content analysis, representing facility needs (rightly sized spaces, functional needs, COVID-19 needs, and improved access) and ambient conditions (clutter, visibility, flooring quality, noise, privacy, cleanliness, aesthetics, and temperature). CONCLUSION: The findings from this study suggest that the interior and exterior facility and ambient conditions of the CAH play a key role in quality and safety outcomes.

Saving Hearts in Rural West Texas: The Impact of Critical Care Access on Mortality Rates.

Background The Critical Access Hospital (CAH) designation program was created in 1997 by the US Congress to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping fundamental services in rural communities. Methods This is a retrospective observational study. Information on CAHs in West Texas in rural counties was extrapolated from the Flex Monitoring Team between 2010 and 2020. The study population included adults aged ≥25 years with a known heart failure (HF) diagnosis who were identified using ICD-10 codes. Mortality rates were obtained from the CDC Wide-ranging ONline Data for Epidemiologic Research (WONDER) database. The HF population was categorized by age, sex, and ethnicity. Mortality differences among these groups were analyzed using a two-sample t-test. The significance level was considered to be p < 0.05. Results The total study population analyzed was 1,348,001. A statistically significant difference in age-adjusted mortality rate (AAMR) was observed between the study and control groups, with a value of 3.200 (95% CI: 3.1910-3.2090, p < 0.0001) in favor of a lower mortality rate in rural counties with CAHs. When comparing gender-related differences, males and females had lower AAMRs in rural counties with CAHs. Among each gender, statistically significant differences were noted between males (95% CI: 2.181-2.218, p < 0.001) and females (95% CI: 3.382-3.417, p < 0.001). When examining the data by ethnicity, the most significant difference in mortality rate was observed within the Hispanic population, 6.400 (95% CI: 6.3770-6.4230, p < 0.0001). When adjusted to age, the crude mortality rate was calculated, which favored CAH admission in the younger population (10.200 (95% CI: 10.1625-10.2375, p < 0.001) and 11.500 (95% CI: 11.4168-11.5832, p < 0.001) in the 55-64 and 65-74 age groups, respectively). Conclusion The data clearly showed that West Texas rural county hospitals that received CAH designation performed better in terms of mortality rates in the HF population compared to non-CAH.

What small rural emergency departments do: a systematic review of observational studies.

OBJECTIVE: Small rural emergency facilities are an important part of emergency care in many countries. We performed a systematic review of observational studies to determine what is known about the patients these small rural emergency facilities treat, what types of interventions they undertake and how well they perform. METHODS: Pubmed/Medline and Embase databases were systematically reviewed between 1980 and the present. Studies were included if they described hospital-affiliated emergency care facilities which were open 24-hours every day, and described themselves as rural, non-urban or non-metropolitan. Studies were excluded if facilities saw more than 15,000 patients annually. Study quality was assessed using 12 previously described indicators. Key activity and performance data were reported for individual studies but not numerically combined between studies. RESULTS: The search strategy found 19 studies that included quantitative data on activity and performance. Nine studies were from Canada, six were from Australia and four from the United States. The settings and scales used varied widely. Few studies adhered to methodological recommendations. The most common presentation was for injury or poisoning (30-53%). The number of patients requiring attention within 15 min was small (2.5-2.8%). Nurses treated many patients without physician input. CONCLUSIONS: There is only enough evidence in the literature to make the most basic inferences about what small rural emergency departments do. To allow evidence-based improvement, descriptive studies must employ measures and methods validated in the wider emergency medicine literature, and other research techniques should be considered.

A comparison of critical access hospitals and other rural acute care hospitals in Pennsylvania.

PURPOSE: As the Flex Program celebrates its 25th anniversary, we examined changes in critical access hospital (CAH) financial performance, investigated whether CAH status has reduced hospitals' financial vulnerability, and identified factors influencing financial performance. METHODS: We collected data on acute care hospitals in Pennsylvania's rural counties for 2000-20. Our sample contained 1,444 hospital-year observations. We used trend analysis to compare the financial performance of CAHs and rural prospective payment system (PPS) hospitals (non-CAHs). We investigated the effect of CAH status on financial performance and identified the time-variant factors impacting financial performance using fixed-effects regression analysis. RESULTS: The median total margin of CAHs lagged behind that of non-CAHs. When compared to non-CAH costs over the same period, the median cost per patient day incurred by CAHs has increased, with the rate of increase being significantly higher in the most recent decade. Our findings show that while CAH status does not appear to have a direct impact on the total margin, it is significantly associated with a higher cost per patient day. CONCLUSIONS: CAHs in Pennsylvania appear to be facing a double whammy of declining margins and rising costs compared to non-CAHs. Our findings demonstrate how crucial the Flex program has been in sustaining CAHs in Pennsylvania ever since its inception. Our findings have implications for rural health care delivery as well. While providing financial support and operational flexibility to CAHs should be a continuing policy priority, a long-term policy goal should be to envision an economic development strategy that capitalizes on the unique strengths of each of the rural archetypes.

Availability of cancer care services and the organization of care delivery at critical access hospitals.

INTRODUCTION: Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas. METHODS: Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs. RESULTS: Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine. CONCLUSION: Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

Cost Effective Virtual Intensive Care Unit Expanding Capabilities in Critical Access Hospitals.

BACKGROUND: Tele-consults provide access to specialized care for a specific question and single point in time. eICU models utilize remote monitoring and ordering but have significant financial burden. We developed a virtual intensive care unit (VICU) for daily input of an intensivist working with local physicians. The purpose was to expand the acute care ability of the critical access hospital (CAH). The study evaluates the impact on the CAH and system. METHODS: The CAH developed an ICU team, led by a hospitalist, who staffed the intensive care unit (ICU). The CAH ICU team rounds daily via a secure video link to provide care in consultation with intensivists based at a university, tertiary care center (TC). A retrospective analysis was conducted 6 months before and after implementation (4/2018-3/2019). Fisher's exact test was used to compare pre- and post-intervention with significance at P < .04. RESULTS: After VICU implementation, there were 265 initial daily and 35 follow-up consults. Monthly transfers to a higher level of care decreased from 63 to 57 (P = .03). Transfers to TC increased from 49.6 to 62.0% (P = .001). Critical access hospital average monthly census and average monthly inpatient days increased (69 to 130 (P < .0001) and 158 to 319 (P < .0001), respectively). Critical access hospital physicians report increased comfort to admit ICU and non-ICU patients due to the program. The total startup cost was $5180. CAH hired 11 providers. There were no unanticipated deaths. DISCUSSION: VICU implementation resulted in new CAH jobs. The CAH experienced increased inpatient census and revenues (ICU and non-ICU) while decreasing patients transferred out of the system.

Telehealth Impact in Frontier Critical Access Hospitals: Mixed Methods Evaluation.

BACKGROUND: Frontier areas are sparsely populated counties in states where 65% of the counties have 6 or fewer residents per square mile. Residents access primary care at critical access hospitals (CAHs) located in these rural communities but must travel great distances for specialty care. Telehealth could address access challenges; however, there are barriers to broader use, including reimbursement and the need for practical implementation support. The Centers for Medicare & Medicaid Services implemented the Frontier Community Health Integration Project (FCHIP) Demonstration to assess the impact of telehealth payment change and technical assistance to adopt and sustainably use telehealth for CAHs treating Medicare fee-for-service patients in frontier regions. OBJECTIVE: We evaluated the impact of the FCHIP Demonstration telehealth payment change and technical assistance on telehealth adoption and ongoing use using a mixed methods approach. METHODS: We conducted a mixed methods evaluation of the 8 CAHs in Montana, Nevada, and North Dakota that participated in the FCHIP program. Key informant interviews and FCHIP program document review were conducted and analyzed using thematic analysis to understand how CAHs implemented their telehealth programs and the facilitators of program adoption and maintenance. Medicare fee-for-service claims were analyzed from August 2013 to July 2019 relative to a group of CAHs that did not participate in the demonstration project to understand the frequency of telehealth use for Medicare fee-for-service beneficiaries receiving care at the participating CAHs before and during the Demonstration program. RESULTS: CAH staff noted several key factors for establishing and sustaining a telehealth program: clinical and administrative staff champions, infrastructure changes, training on telehealth processes, and establishing strong relationships with specialists at distant facilities to deliver telehealth services to patients of CAH. There was a modest increase in telehealth services billed to Medicare during the FCHIP Demonstration that were limited to a handful of CAHs. CONCLUSIONS: The frontier setting is characterized by a low population; and thus, the volumes of telehealth services provided in both the CAHs and comparison sites are low. Overall, CAHs reported that patient satisfaction was high and expressed the desire for more virtual services. Telehealth service selection was informed by perceived community needs and specialist availability. CAHs made infrastructure changes to support telehealth and expressed the desire for more virtual services. Implementation support services helped CAHs integrate telehealth into clinical and operational workflows. There was some increase in telehealth services billed to Medicare, but the volume billed was low and not enough to substantially improve hospital revenue. Future work to inform policy and practice could include standardized, formal community need assessments and assistance finding distant providers to meet those needs and further technical assistance around billing, service selection, and ongoing use to support sustainability.

Advanced Endoscopic Evaluation of Gastroesophageal Reflux Disease in Morbidly Obese Patients in a Rural Setting.

INTRODUCTION: Obesity is a known risk factor for gastroesophageal reflux disease (GERD). Morbidly obese patients in rural areas are usually referred to the local surgeon for endoscopic evaluation. This situation poses significant challenges given the increased risk for perioperative complications due to anatomical and metabolic factors. This study aims to evaluate the safety of performing GERD diagnostic workup studies in a rural setting. METHODS: Institutional review board approval was obtained for a retrospective chart review of patients who presented with GERD symptoms to a rural antireflux clinic between August 2015 and October 2020. Patients were included if their body mass index (BMI) was over 35 with comorbidities or over 40 kg/m2 who underwent upper gastrointestinal endoscopy with or without concomitant placement of wireless pH probe and/or functional luminal imaging probe. RESULTS: A total of 117 patients met the inclusion criteria. There were 94 (80.3%) females and 23(19.7%) males. The average age was 56.0 ± 13.4 years. The average BMI was 40.4 (35-66.4). Proton pump inhibitor use was noted in 97/117 (82.9%) with an average duration of 12.0 ± 9.2 years. The average GERD-Health Related Quality of Life, Reflux Symptom Index and GERD Symptom Score (GERSS) were 29.8 ± 20, 24.5 ± 14.2 and 21.3 ± 15.4 respectively. There were no procedural complications. All the endoscopic examinations were successfully completed and patients were discharged. CONCLUSION: Performing diagnostic studies for GERD for morbidly obese patients in critical access hospitals is safe. Patient selection, proper training and adequate preparation are critical prerequisites for good outcomes.

Evaluation of the American Hospital Association Annual Survey for health services research in emergency medicine.

Objectives: Emergency department (ED) data are often used to address questions about access to and quality of emergency care. Our objective was to compare one of the most commonly used data sources for national ED information, the American Hospital Association (AHA) Annual Survey, with a criterion database: the National Emergency Department Inventory (NEDI)-USA data set. Methods: We compared the 2015 and 2016 AHA surveys to the following 3 criterion standards: (1) the 2015 and 2016 NEDI-USA databases, which have information about all US EDs, including merged data from (2) Council of Teaching Hospitals (COTH) and (3) the Critical Access Hospital (CAH) program. We present descriptive results about the number of EDs in each data set; total and median visit volumes; locations in rural areas; and COTH, CAH, and freestanding ED (FSED) status. Results: The AHA survey identified 3893 US EDs in 2015. These EDs had a total annual visit volume of 129,197,493 visits, with a median of 22,772 visits (interquartile range, 8311-47,938). Compared with the NEDI-USA, the AHA included 1433 fewer EDs (-27%; 95% confidence interval [CI], -28% to -26%) and 23,615,163 (-15%) fewer visits. Specifically, AHA was missing 245 (-22%; 95% CI, -24% to -19%) of those located in rural areas, 268 (-20%; 95% CI, -22% to -18%) in a CAH, and 240 (-47%; 95% CI, -51% to -42%) FSEDs. We saw similar results using 2016 data. Conclusions: Although several aggregated results were similar between the compared data sources, the AHA data set excluded many US EDs, including many rural EDs and FSEDs. Consequently, the AHA underreported total ED visits by 15%. We encourage data users to be cautious when interpreting results from any 1 ED data source, including the AHA.

Trends in Rural Outreach by Orthopedic Surgeons.

BACKGROUND: Sixty million rural residents have limited access to orthopedic care due to a small rural orthopedic surgery workforce. Increases in specialized training add to the challenge of attracting orthopedic surgeons to rural communities. Answering the call for research on models to meet the needs of rural orthopedic patients, we examine long-term trends in visiting consultant clinics (VCCs) in Iowa, a state with a large rural population. METHODS: The Office of Statewide Clinical Education Programs (Carver College of Medicine) compiles an annual report of outreach clinic locations, frequencies and participating physicians. Trends in the total number of VCCs, days and locations (1989-2018) were analysed using joinpoint analysis. RESULTS: Total clinic days grew rapidly from 1992-1997 (Average Percent Change: 19.7%) before a decline ending in 2009 (APC: -4.1%). A new growth period (2009-2013, APC: 7.5%) preceded another decline (APC: -3.6%) ending in 2018. The number of cities hosting a VCC grew from 56 (1989) to a peak of 90 (1999) and fell an average of 0.9% a year thereafter. More than 80% of all VCCs in the last ten years were offered 2 or more times per month. The average participation rate for Iowa-based orthopedic surgeons was 44%. The mean number of VCCs staffed by a single physician was 1.32 (std. dev. = 0.53) with a median of 1. The average number of VCC days per month for a participating physician was 3.22 (std. dev. = 2.41) with a median of 2.66. CONCLUSION: The VCC model of rural outreach is sustainable (30+ year history) and self-funded. Most clinics occur with sufficient frequency to allow timely follow-up care. This model of rural outreach is supported by the participation of a large segment (44%) of Iowa's orthopedic surgeons. Visiting orthopedic surgeons provide access to care in 65 of the 76 Critical Access Hospitals in Iowa offering orthopedic services compared to 8 staffed by a local orthopedic surgeon.Level of Evidence: V.

The Value Surgical Services Bring to Critical Access Hospitals.

Purpose Critical Access Hospitals (CAHs) serve rural populations and receive government subsidies to compensate for their relatively high overhead costs and low occupancy rates. Twenty-nine percent of all hospitalizations in the United States include a surgical procedure, and hospitalizations involving surgery accounted for nearly half of all hospital revenue in 2011. This study aims to determine the value surgical services bring to CAHs and their impact on the viability of these facilities.  Methods Public access data from the American Hospital Directory (AHD) was analyzed about each hospital's revenue and surgical services offered. Excel was utilized to randomly select 300 CAHs from a pool of 1350 CAHs based on a 95% confidence interval and a 5% margin of error. Linear regression models were fit to the data evaluating the association of net income with the number of surgical services offered per hospital and the association of total margin with the number of surgical services offered per hospital. Models were adjusted for location, occupancy rate, and case mix index.  Findings The linear regression model demonstrated that for every additional surgical service provided by a CAH, the hospital net income increased by $630,528 (p=0.0032). A similar trend was observed when modeling profitability. The total margin increased 0.73% for each additional surgical service added, albeit without statistical significance (p=0.1342). CAHs providing two or three surgical services showed tighter group variance than those not offering surgery or only offering one surgical service.  Conclusions Net income was significantly correlated to the number of surgical services offered at CAHs. Furthermore, CAHs offering more surgical services seem to have more predictable profits than those offering less surgical services. CAHs would financially benefit from offering more or expanding surgical services at their facilities.

Rural infection preventionists' experiences during the COVID-19 pandemic: Findings from focus groups conducted with association of professionals in infection control & epidemiology (APIC) members.

BACKGROUND: SARS CoV-2, the virus that causes COVID-19, was identified and quickly developed into a pandemic in spring, 2020. This event posed immense difficulties for healthcare nationally, with rural areas experiencing different challenges than other regions. METHODS: The Association of Professionals in Infection Control & Epidemiology conducted focus groups with infection preventionist (IP) members in September and October, 2020. Zoom sessions were recorded and transcribed. Content analysis was used to identify themes. RESULTS: In all, 38 IPs who work at a critical access hospital or a healthcare facility in a rural location participated. Major challenges identified by IPs in this study included addressing the lack of access to personal protective equipment (PPE), overwhelming workloads caused by the pandemic and multiple roles/responsibilities, inaccurate social media messages, and generalized disbelief and disregard about the pandemic among rural community members. CONCLUSIONS: Gaps in preparedness identified in this study, such as the lack of PPE, need to be addressed to prevent occupational illness. In addition, health disparities and inaccurate beliefs about COVID-19 heard by IPs in this study need to be addressed in order to increase compliance with public health safeguards among rural community members and minimize morbidity and mortality in these regions.

Regional Specialty Surgical Practice Efficiencies Gained as a Result of COVID-19.

OBJECTIVE: To identify opportunities for discontinuing elective and nonemergency surgical cases in a regional surgical practice in response to coronavirus disease 2019 (COVID-19). PATIENTS AND METHODS: COVID-19 began to affect surgical practices across the United States in March 2020. On March 17, 2020, all elective and nonemergency surgical care was deferred to prepare the Mayo Clinic Health System sites in northwestern Wisconsin for an anticipated surge in patients with COVID-19. When the decision was made to reactivate the surgical practice, several major structural and operational changes were made to the regional surgical practice to optimize efficiencies. RESULTS: The structural and operational changes implemented during reactivation resulted in improved utilization of surgical resources including improvement in operating room (OR) block utilization, increased available OR time, and increased case volumes. CONCLUSION: Surgical and procedural leaders should consider a limited-time deferral of elective surgical cases to implement widespread OR efficiency strategies. The time selected for deferral of surgical cases should target a period of historically low surgical volume to minimize disruption to patient care and impact on overall OR functions.