MMA Quality Review, September 2008 - Ira Moscovice, Ph.D., director of the University of Minnesota Rural Health Research Center, has been at the forefront of efforts to develop quality and patient safety measures for rural clinics and hospitals. Here are his views on the quality of health care in greater Minnesota.


Q: How do you define rural Minnesota?
A: One of the easiest ways is to look at counties. All counties are designated as metro or nonmetro. In Minnesota, the Metropolitan Statistical Areas include the areas around the cities of Minneapolis and St. Paul, St. Cloud, Rochester, Duluth, Fargo, Grand Forks, and La Crosse.

Q: What do we know about the quality of health care in rural Minnesota?
A: The data we have is on the inpatient side from Hospital Compare, which is based on Medicare data. What we’ve seen over the past three years nationally and in Minnesota is that rural hospitals are lagging on almost all of the heart attack quality measures and most of the congestive heart failure quality measures. However, rural hospitals do better on some of the pneumonia and surgical-infection prevention measures. So there is work to be done in rural hospitals.

Q: Have rural hospitals been closing the quality gap between them and urban hospitals?
A: Quality has been improving for both urban and rural hospitals, but the relative gap has stayed the same.

Q: Why is there a gap?
A: It could be due to a variety of issues: staffing levels, organizational culture with respect to quality improvement, a lack of specialists and technology, a lack of connections with external entities and partners, and not using clinical guidelines and protocols. It could also be a volume issue, poor documentation. It is still an open question.

Q: Could the difference be caused by the characteristics of rural patients?
A: The rural population is a bit older, sicker, and has less health insurance coverage. So that could explain a portion of the results.
Q: Do rural hospitals do better in some areas?
A: Centers for Medicare and Medicaid Services (CMS) has just released its first set of patient satisfaction data, and guess what? Smaller hospitals had the highest rating, which is not surprising because the patient-provider relationship is different in the rural environment. Rural hospitals have also performed well on the pneumonia measures.

Q: Do rural hospitals have any other advantages?
A: Systems theory indicates that smaller size and scale should better facilitate the implementation of quality-improvement strategies. Rural hospitals are less complex and should be able to address quality and safety issues much more directly.

Q: Are there any measures for rural ambulatory care?
A: Almost half of the revenue of smaller rural hospitals is on the outpatient side. So the ambulatory side is really important. CMS has just started some demonstrations to look at the quality of ambulatory care provided by physicians and is also starting to look at outpatient hospital measures. Where I really see things evolving is toward collecting information on quality of episodes of inpatient and outpatient care over time.

Q: Part of your work has been to develop rural-specific measures. What did you come up with?
A: Two of the core functions of a rural hospital are emergency care and transferring patients. So we developed a set of quality measures for the timeliness of care for heart attack patients and a set of measures for patient transfers that start with whether the appropriate information was communicated between health providers.

Q: Tell me more.
A: For instance, what was the median time for a heart attack patient to get an aspirin, an EKG, and other appropriate tests? As for transfers, we monitor whether vital information such as demographic information, information about medications, vital signs, and so forth was communicated from the rural hospital out to the receiving hospital.

Q: Are these measures being used by CMS?
A: Larger hospitals started using the timeliness measures in July, and rural hospitals are scheduled to start using them by January 1, 2009. The National Quality Forum has endorsed the transfer measures, and we are hoping that CMS will start using them next year.

Q: Is there a measure for whether the hospital made the right decision about transferring the patient?
A: No, but that is where our work is heading Another obvious question is, How did the patient do? What was their outcome? But that also gets much more complicated.

Q: Should rural providers have different measures than urban providers?
A: I don’t think we want to develop measures just for rural hospitals. The kinds of issues at the core of how a rural hospital performs are also relevant for other hospitals. On the other hand, I think it is very important to have that rural-specific information at the local level and to understand the differences across settings, because if we need improvement in both rural and urban hospitals, the solutions may be different.

Q: Have we been too lax about measuring the quality of rural hospitals?
A: Historically, rural hospitals were allowed to be exempt from these efforts because they didn’t have the volume. However in recent years, there has been a real push from Health Resources and Services Administration to provide states resources to work with critical access hospitals on their quality improvement. Today, about three-fourths of the critical access hospitals nationally and in Minnesota participate in quality reporting, even though they don’t have a financial incentive to do so.

Q: Should their participation be mandated?
A: I believe Stratis Health has been real successful in Minnesota in increasing critical access hospital participation at a rate of about 10 percent a year for the last few years. Hopefully, we can approach 100 percent participation with a voluntary program.

Q: What needs to be done to help rural providers improve their quality?
A: At the macro level, we need to build a rural health information technology infrastructure. We also need to make sure that rural hospitals participate in quality initiatives and that relevant measures are being used. The Joint Commission, National Quality Forum, and CMS have all become much more sensitive about the rural aspects of quality. We are moving in the right direction.
Another challenge is just the sheer financial stability of smaller institutions.
As for individual hospitals, the most important thing is to collect and report quality data and outcomes on a regular basis both within your institution and to the public.