An article in the April 3rd issue of JAMA describes the higher mortality from acute MI, congestive health failure and pneumonia in critical access hospitals (CAHs) (small hospitals in sparsely populated areas). The authors reasoned that the difference was due to the fact that most hospitals have quality reporting programs but CAHs do not. But CAHs lack another important ingredient: specialists. While the counties with and without CAHs had similar numbers of generalist physicians (about 50 per 100,000), counties with CAHs averaged only 14 specialists per 100,000 while other counties averaged 100 specialists per 100,000, a seven-fold difference.
Over the period of observation (2002-2010), mortality improved in some CAHs but not in others. There was no difference in the average numbers of generalists in the counties where improvement occurred vs. where it did not, but the number of specialists was 30% greater in the counties where mortality in CAHs improved.
There was a lot of variability in the data, so the statistics are not strong. But we know that the evolving specialist shortage hits remote areas first. Are CAHs showing us what happens when there aren’t enough specialists? Could CAHs be the canary in mine?