Quality‐of‐Care Challenges for Rural Health

Abstract

The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.

The Changing Nature of Rural Health Care

“…Keeler and colleagues (46) drew strong responses from other researchers and rural health advocates when they found that rural and nonteaching hospitals have lower levels of quality (9). The rural research center at the University of Minnesota completed an overview of issues related to quality of care in rural versus other places in the United States (57). This review points to the few studies of quality that consider rural conditions and the realities of the workforce and practice conditions in rural communities.…”

“…However, developments in technology and organization, including the expansion of the use of telemedicine and an increase in the numbers of rural hospitals and rural practitioners becoming parts of alliances and systems, captured the attention of rural health services researchers as well as policy makers. As quality of care became an important issue and a larger proportion of the nation's population was covered by managed-care plans (34), rural providers were not left out of the trend toward greater scrutiny over practice decisions, especially when costs could be reduced (57). More attention is being ?…”

From surviving to community benefit: A proposed rural health services research agenda

“…Quality of care has received the bulk of attention starting in 1999 [28] with a concern for the challenges of rural quality of care, appropriate assessment tools, and the need to clarify a primary quality-of-care objective [29] . It was argued that rural facilities should demonstrate an ability to provide care at a level of quality comparable to urban organizations.…”

“…It was argued that rural facilities should demonstrate an ability to provide care at a level of quality comparable to urban organizations. Since then, the research question has focused on how best to define, measure [29,30] , compare [31,32] , and report quality-of-care outcomes [14] in rural facilities, especially CAHs.…”

“…A subsequent study reports a comparatively higher mortality rate among Medicare beneficiaries admitted to CAHs than those admitted to non-CAHs for the same three conditions [34] . Additional studies have raised concerns over the relevance of quality measures for CAHs and outpatient services [29] .…”