Nursing home closures and access to post-acute care and long-term care services in rural areas.

PURPOSE: Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures. METHODS: We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018. FINDINGS: Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles. CONCLUSIONS: Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments.

BACKGROUND: Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. METHODS: Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. RESULTS: In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. CONCLUSIONS: Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Comparison of Telehealth and In-Person Behavioral Health Services and Payment in a Large Rural Multisite Usual Care Study.

Background: Telehealth and in-person behavioral health services have previously shown equal effectiveness, but cost studies have largely been limited to travel savings for telehealth cohorts. The purpose of this analysis was to compare telehealth and in-person cohorts, who received behavioral health services in a large multisite study of usual care treatment approaches to examine relative value units (RVUs) and payment. Methods: We used current procedural terminology codes for each encounter to identify RVUs and Medicare payment rates. Mixed linear regression models compared telehealth and in-person cohorts on RVUs, per-encounter payment rates, and total-episode payment rates. Results: We found the behavioral health services provided by telehealth to have modest, but statistically significantly lower RVUs (i.e., less provider work in time spent and case complexity), per-encounter payments, and total episode payments than the in-person cohort. Despite Medicare rates discounting payments for nonphysician providers and the in-person cohort using clinical social workers more frequently, the services provided by the telehealth cohort still had lower payments. Thus, the differences observed are due to the in-person cohort receiving higher payment RVU services than the telehealth cohort, which was more likely to receive briefer therapy sessions and other less expensive services. Conclusions: Behavioral health services provided by telehealth used services with lower RVUs than behavioral health services provided in-person, on average, even after adjusting for patient demographics and diagnosis. Observed differences in Medicare payments resulted from the provider type and services used by the two cohorts; thus, costs and insurance reimbursements may vary for others.

Medicare accountable care organization characteristics associated with participation in 2-sided risk.

PURPOSE: To examine the associations of accountable care organization (ACO) characteristics with the likelihood of participation in 2-sided risk tracks in the Medicare Shared Savings Program (SSP). METHODS: CMS ACO Public Use Files and Provider-Level Research Identifiable Files were used to trace Medicare ACOs' participation in the SSP between 2012 and 2020 and measure ACO characteristics, including size, rurality of the service area, affiliation with supporting organizations, program experience, and performance. Logistic regression and survival analysis were used to test the associations between ACO characteristics and the probability of ACOs initially participating in or subsequently switching to 2-sided risk tracks. FINDINGS: Among the 624 Medicare SSP ACOs that started between 2012 and 2017, 26 participated in 2-sided risk tracks in their initial contracts and 95 switched to 2-sided risk tracks subsequently. ACO characteristics were not significantly associated with the probability of participating in 2-sided risk tracks in initial contracts. ACO size, affiliation with supporting organizations, and performance were positively associated with the likelihood of switching to 2-sided risk. Rural ACOs were less likely to switch to 2-sided risk than their urban counterparts. CONCLUSIONS: Small and rural ACOs are less prepared to transition into 2-sided risk swiftly.

The impact of Medicare shared savings program participation on hospital financial performance: An event-study analysis.

OBJECTIVE: To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance. DATA SOURCES: Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018. STUDY DESIGN: We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate. DATA COLLECTION/EXTRACTION METHODS: Secondary data linked at the hospital level. PRINCIPAL FINDINGS: Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years. CONCLUSIONS: MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study.

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).

Sepsis is a severe condition that results from infection. In addition to costly care, sepsis is a leading cause of death and disability. When comparing outcomes, those treated for sepsis in lower volume emergency departments fare worse and rural emergency departments often have lower patient volumes. While telehealth has been shown to improve sepsis care, the effect of telehealth on costs and long-term outcomes for patients is unclear. This study will use Medicare claims data to compare outcomes for people with sepsis in rural emergency departments who had video telehealth used with those who did not have video telehealth used, with the goal of measuring how telehealth affects healthcare costs, hospital readmissions and deaths after hospital discharge.

HRSA's evidence-based tele-emergency network grant program: Multi-site prospective cohort analysis across six rural emergency department telemedicine networks.

BACKGROUND: The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) funded the Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) to serve the dual purpose of providing telehealth services in rural emergency departments (teleED) and systematically collecting data to inform the telehealth evidence base. This provided a unique opportunity to examine trends across multiple teleED networks and examine heterogeneity in processes and outcomes. METHOD AND FINDINGS: Six health systems received funding from HRSA under the EB TNGP to implement teleED services and they did so to 65 hospitals (91% rural) in 11 states. Three of the grantees provided teleED services to a general patient population while the remaining three grantees provided teleED services to specialized patient populations (i.e., stroke, behavioral health, critically ill children). Over a 26-month period (November 1, 2015 -December 31, 2017), each grantee submitted patient-level data for all their teleED encounters on a uniform set of measures to the data coordinating center. The six grantees reported a total of 4,324 teleED visits and 99.86% were technically successful. The teleED patients were predominantly adult, White, not Latinx, and covered by Medicare or private insurance. Across grantees, 7% of teleED patients needed resuscitation services, 58% were rated as emergent, and 30% were rated as urgent. Across grantees, 44.2% of teleED patients were transferred to another inpatient facility, 26.0% had a routine discharge, and 24.5% were admitted to the local inpatient facility. For the three grantees who served a general patient population, the most frequent presenting complaints for which teleED was activated were chest pain (25.7%), injury or trauma (17.1%), stroke symptoms (9.9%), mental/behavioral health (9.8%), and cardiac arrest (9.5%). The teleED consultation began before the local clinician exam in 37.8% of patients for the grantees who served a general patient population, but in only 1.9% of patients for the grantees who provided specialized services. CONCLUSIONS: Grantees used teleED services for a representative rural population with urgent or emergent symptoms largely resulting in transfer to a distant hospital or inpatient admission locally. TeleED was often available as the first point of contact before a local provider examination. This finding points to the important role of teleED in improving access for rural ED patients.

Averted Transfers in Rural Emergency Departments Using Telemedicine: Rates and Costs Across Six Networks.

Objective: This analysis identified the rate of transfers and averted transfers and their associated costs across multiple emergency department telemedicine (teleED) networks. Methods: This study is a prospective cohort analysis in six teleED networks operating in 65 hospitals in 11 states across the United States. Each submitted uniform data on all teleED encounters for a 26-month period to a data co-ordinating center. Averted transfers were identified if an encounter met specific criteria. Cost savings from averted transfers were estimated from hospital-specific costs of transferred patients. Results: A total of 4,324 teleED encounters were reported. Excluding patients who died, 1,934 (46.2%) were transferred to another inpatient facility. Records of the remaining 2,248 teleED patients were examined and 882 (39.2% of nontransfers; 20.4% of all teleED cases) teleED patients met the criteria for an averted transfer. Of the averted transfer cases, 53.3% were admitted to the local inpatient facility, and 43.5% were discharged. Patients who averted transfer had lower levels of severity and less billed services than those who were transferred. Transport savings for averted transfers were estimated to total $1,074,663 annually across the six teleED networks. Average estimated transport savings were $2,673 for each averted transfer. Conclusions: In a large cohort of teleED cases, 39% of nontransfer cases were averted transfers (20% of all teleED cases). Importantly, 43% of these patients were routinely discharged rather than being transferred. Averted transfers saved on average $2,673 in avoidable transport costs per patient, with 63.6% of these cost savings accruing to public insurance.

Organizational Attributes Associated With Medicare ACO Quality Performance.

PURPOSE: To evaluate associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance. METHODOLOGY: We conducted cross-sectional and longitudinal analyses of ACO quality performance using data from the Centers for Medicare and Medicaid Services and additional sources. The sample included 322 and 385 MSSP ACOs that had successfully reported quality measures in 2014 and 2015, respectively. RESULTS: Results show that after adjusting for other organizational factors, rural ACOs' average quality score was comparable to that of ACOs serving other geographic categories. ACOs with hospital-system sponsorship, larger beneficiary panels, and higher posthospitalization follow-up rates achieved better quality performance. CONCLUSION: There is no significant difference in average quality performance between rural ACOs and other ACOs after adjusting for structural and service-provision factors. MSSP ACO quality performance is positively associated with hospital-system sponsorship, beneficiary panel size, and posthospitalization follow-up rate.

Changes to the Merit-based Incentive Payment System Pertinent to Small and Rural Practices, 2018.

This brief highlights key regulatory changes to the Merit-based Incentive Payment System (MIPS) in 2018. We discuss the importance of these changes, particularly as they affect small and rural practices.

Spread of Medicare Accountable Care Organizations in Rural America.

Purpose: This RUPRI Center data report describes Medicare accountable care organization (ACO) growth in non-metropolitan U.S. counties from 2016 to 2017. This data report, which includes data through December 2017, follows a similar analysis released in October 2016 that described ACO trends from 2013 to 2015. Key Findings: The following findings are based on activity through 2017: (1) Medicare ACOs operate (an ACO provider is present) in 60.3 percent of all nonmetropolitan counties, up from 41.8 percent in 2016, (2) As of December 2017, no nonmetropolitan ACOs were participating in ACO models that included downside risk (meaning they are liable for expenditures exceeding a benchmark).

Update: Independently Owned Pharmacy Closures in Rural America, 2003-2018.

This Policy Brief continues the series of reports from the RUPRI Center updating the number of pharmacy closures in rural America with annual data. See our website for other analyses of trends and assessment of issues confronting rural pharmacies. Key Findings: (1) Over the last 16 years, 1,231 independently owned rural pharmacies (16.1 percent) in the United States have closed. The most drastic decline occurred between 2007 and 2009. This decline has continued through 2018, although at a slower rate. (2) 630 rural communities that had at least one retail (independent, chain, or franchise) pharmacy in March 2003 had no retail pharmacy in March 2018.

Using tele-emergency to avoid patient transfers in rural emergency departments: An assessment of costs and benefits.

Introduction Tele-emergency can address several challenges facing emergency departments in rural areas. The purpose of this paper is to (a) examine the rates of avoided transfers in rural emergency departments that adopted tele-emergency applications; and (b) estimate the costs and benefits of using tele-emergency to avoid transfers. Methods Analysis is based on 9048 tele-emergency encounters generated by the Avera eEmergency programme (Sioux Falls, South Dakota) in 85 rural hospitals across seven states between October 2009-February 2014. For each non-transfer patient, physicians indicated whether the transfer was avoided because of tele-emergency activation. The cost-benefit analysis is conducted from the hospital, patient and societal perspectives, and includes technology costs, local hospital revenues and patient-associated savings. All monetary values are expressed in US$. Sensitivity analysis is conducted by examining the worst and best case scenarios of costs, revenues and savings. Results In these analyses, 1175 avoided transfers were attributed to tele-emergency. From a rural hospital perspective, tele-emergency costs around US$1739 to avoid a single transfer. However, tele-emergency saves around US$5563 in avoided transportation and indirect patient costs. Combining these, from a societal perspective, tele-emergency has the potential to result in a net savings of US$3823 per avoided transfer while accounting for tele-emergency technology costs, hospital revenues, and patient-associated savings. Conclusion This study highlights various stakeholder perspectives on the financial impact of tele-emergency in avoiding patient transfers in rural emergency departments. Telemedicine has the potential to reduce the number of transfers of emergency department patients and generate some revenue for rural hospitals despite associated technology costs, while incurring substantial patient savings.

Rural Bypass of Critical Access Hospitals in Iowa: Do Visiting Surgical Specialists Make a Difference?

PURPOSE: Rural bypass for elective surgical procedures is a challenge for critical access hospitals, yet there are opportunities for rural hospitals to improve local retention of surgical candidates through alternative approaches to developing surgery lines of business. In this study we examine the effect of visiting surgical specialists on the odds of rural bypass. METHODS: Discharge data from the 2011 State Inpatient Databases and State Ambulatory Surgery Databases for Iowa were linked to outreach data from the Office of Statewide Clinical Education Programs and Iowa Physician Information System to model the effect of surgeon specialist supply on rural patients' decision to bypass rural critical access hospitals. FINDINGS: Patients in rural communities with a local general surgeon were more likely to be retained in a community than to bypass. Those in communities with visiting general surgeons were more likely to bypass, as were those in communities with visiting urologists and obstetricians. Patients in communities with visiting ophthalmologists and orthopedic surgeons were at higher odds of being retained for their elective surgeries. CONCLUSION: In addition to known patient and local hospital factors that have an influence on bypass behavior among rural patients seeking elective surgery, availability of surgeon specialists also plays an important role in whether patients bypass or not. Visiting ophthalmologists and orthopedic surgeons were associated with less bypass, as was having local general surgeons. Visiting general surgeons, urologists, and obstetricians were associated with greater odds of bypass.

Financial Performance of Rural Medicare ACOs.

PURPOSE: The Centers for Medicare & Medicaid Services (CMS) has facilitated the development of Medicare accountable care organizations (ACOs), mostly through the Medicare Shared Savings Program (MSSP). To inform the operation of the Center for Medicare & Medicaid Innovation's (CMMI) ACO programs, we assess the financial performance of rural ACOs based on different levels of rural presence. METHODS: We used the 2014 performance data for Medicare ACOs to examine the financial performance of rural ACOs with different levels of rural presence: exclusively rural, mostly rural, and mixed rural/metropolitan. RESULTS: Of the ACOs reporting performance data, we identified 97 ACOs with a measurable rural presence. We found that successful rural ACO financial performance is associated with the ACO's organizational type (eg, physician-based) and that 8 of the 11 rural ACOs participating in the Advanced Payment Program (APP) garnered savings for Medicare. Unlike previous work, we did not find an association between ACO size or experience and rural ACO financial performance. CONCLUSIONS: Our findings suggest that rural ACO financial success is likely associated with factors unique to rural environments. Given the emphasis CMS has placed on rural ACO development, further research to identify these factors is warranted.

Use Of Telemedicine For ED Physician Coverage In Critical Access Hospitals Increased After CMS Policy Clarification.

There is a chronic shortage of physicians to cover emergency departments (EDs) in critical access hospitals. A 2013 memorandum from the Centers for Medicare and Medicaid Services clarified that a telemedicine physician could fulfill the regulatory requirements for physician backup when advanced practice providers were at telemedicine-equipped critical access hospital EDs but local physicians were not. In a sample of nineteen hospitals, coverage schedules in 2016 showed that seven had begun the use of tele-ED physician backup for advanced practice providers, decreasing local physician coverage in their EDs. These seven hospitals tended to have decreasing ED staffing costs, while the hospitals not applying this policy showed continually increasing staffing costs over time. Telemedicine also provided other benefits, such as improved physician recruitment and retention. In the future, more critical access hospitals will likely use telemedicine to provide physician backup for advanced practice providers staffing the ED.

Genetic Predisposition to Obesity and Medicare Expenditures.

BACKGROUND: The relationship between obesity and health expenditures is not well understood. We examined the relationship between genetic predisposition to obesity measured by a polygenic risk score for body mass index (BMI) and Medicare expenditures. METHODS: Biennial interview data from the Health and Retirement Survey for a nationally representative sample of older adults enrolled in fee-for-service Medicare were obtained from 1991 through 2010 and linked to Medicare claims for the same period and to Genome-Wide Association Study (GWAS) data. The study included 6,628 Medicare beneficiaries who provided 68,627 complete person-year observations during the study period. Outcomes were total and service-specific Medicare expenditures and indicators for expenditures exceeding the 75th and 90th percentiles. The BMI polygenic risk score was derived from GWAS data. Regression models were used to examine how the BMI polygenic risk score was related to health expenditures adjusting for demographic factors and GWAS-derived ancestry. RESULTS: Greater genetic predisposition to obesity was associated with higher Medicare expenditures. Specifically, a 1 SD increase in the BMI polygenic risk score was associated with a $805 (p < .001) increase in annual Medicare expenditures per person in 2010 dollars (~15% increase), a $370 (p < .001) increase in inpatient expenses, and a $246 (p < .001) increase in outpatient services. A 1 SD increase in the polygenic risk score was also related to increased likelihood of expenditures exceeding the 75th percentile by 18% (95% CI: 10%-28%) and the 90th percentile by 27% (95% CI: 15%-40%). CONCLUSION: Greater genetic predisposition to obesity is associated with higher Medicare expenditures.

Telepharmacy Rules and Statutes: A 50-State Survey.

Purpose and Introduction. The purpose of this policy brief is to identify rules and laws enacted by states authorizing the use of community telepharmacy initiatives within their respective jurisdictions. Though telepharmacy exists in several forms, telepharmacy in this brief is defined as the delivery of pharmaceutical care to outpatients at a distance through the use of telecommunication and other advanced technologies. Pharmaceutical care includes, but is not limited to, drug review and monitoring, dispensing of medications, medication therapy management, and patient counseling. A significant advantage of telepharmacy is the ability to provide pharmacist access to patients in remote areas where a pharmacist is not physically available. Therefore, the implications of telepharmacy on increasing access to care are significant, particularly to patients in underserved rural communities, though it is important to note that underserved populations do not exist exclusively in rural settings. Key Findings. (1) The use of telepharmacy is authorized, in varying capacities, in 23 states (46 percent). (2) Pilot program development that could apply to telepharmacy initiatives is authorized by six states (12 percent). (3) Waivers to administrative or legislative pharmacy practice requirements that could allow for telepharmacy initiatives are permitted in five states (10 percent). (4) Nearly one-third of the states (16, or 32 percent) do not authorize the use of telepharmacy, nor do they currently have the ability to pursue telepharmacy initiatives via pilot programs or waivers.

Issues Confronting Rural Pharmacies after a Decade of Medicare Part D.

Purpose. The RUPRI Center for Rural Health Policy Analysis has been monitoring the status of rural independent pharmacies since the implementation of Medicare Part D in 2005. After a decade of Part D, we reassess in this brief the issues that concern rural pharmacies and may ultimately challenge their provision of services. This reassessment is based on survey responses from rural pharmacists. Key Findings: (1) Rural pharmacists indicated that two challenges--direct and indirect remuneration (DIR) fees, and delayed maximum allowable cost (MAC) adjustment--ranked highest on scales of both magnitude and immediacy. Nearly eighty (79.8) percent of respondents reported DIR fees as a very large magnitude challenge, with 83.3 percent reporting this as a very immediate challenge. Seventy-eight percent of respondents reported MACs not being updated quickly enough to reflect changes in wholesale drug costs as a very large magnitude challenge, with 79.7 percent indicating it as a very immediate challenge. (2) Medicare Part D continues to be a concern for rural pharmacies--58.8 percent of pharmacists said being an out-of-network pharmacy for Part D plans was a very large magnitude challenge (an additional 29.0 percent said large magnitude) and 60.5 percent said it was a very immediate challenge (an additional 28.1 percent said moderately immediate). (3) Pharmacy staffing, competition from pharmacy chains, and contracts for services for Medicaid patients were less likely to be reported as significant or immediate challenges.

Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?

PURPOSE: The aim of the study was to examine whether Critical Access Hospitals (CAHs), the predominant type of hospital in small and isolated rural areas, perform better than, the same as, or worse than Prospective Payment System (PPS) hospitals on measures of quality. METHODS: The Healthcare Cost and Utilization Project State Inpatient Databases and American Hospital Association annual survey data were used for analyses. A total of 35,674 discharges from 136 nonfederal general hospitals with fewer than 50 beds were included in the analyses: 14,296 from 100 CAHs and 21,378 from 36 PPS hospitals. Outcome measures included 6 bivariate indicators of adverse events (including complications) of surgical care developed from the Agency for Healthcare Research and Quality's Patient Safety Indicators. Multiple logistic regression models were developed to examine the relationship between hospital adverse events and CAH status. FINDINGS: Compared with PPS hospitals, CAHs are significantly less likely to have any observed (unadjusted) adverse event on 4 of the 6 indicators. After adjusting for patient mix and hospital characteristics, CAHs perform better on 3 of the 6 indicators. Accounting for the number of discharges eliminated the differences between CAHs and PPS hospitals in the likelihood of adverse events across all indicators except one. CONCLUSIONS: The study suggests there are no differences in surgical patient safety outcomes between CAHs and PPS hospitals of comparable size. This reinforces the central role of CAHs in providing quality surgical care to populations in rural and isolated areas, and underscores the importance of strategies to sustain rural surgery infrastructure.