Quality of Care and Hospital Bypass Among Rural Heart Failure Patients

Rural patients are increasingly seeking care from hospitals in urban areas, in a phenomenon known as rural hospital bypass, wherein a patient bypasses the nearest rural hospital to them for a more distant one. Increasing bypass results in longer travel times for patients and reduced financial stability for hospitals, which have downstream impacts on healthcare access for rural communities. This mixed-methods studies uses quantitative analysis to evaluate factors associated with hospital choice for emergency care among rural heart failure patients, including hospital quality measures, and the association of bypass and quality measures with receipt of follow-up care after discharge. It uses qualitative methods to understand patient perspectives on hospital choice and quality-of-care.

In Aim 1, we found that quality measures were associated with hospital choice, as hospitals performing better on five quality measures had greater odds of being used for an emergency department (ED) encounter. While these associations were statistically significant, they were much smaller compared with other covariates such as travel distance and hospital resources. We also found that socioeconomically disadvantaged patients were not more likely to use better-performing hospitals. In Aim 2, we found that patients who used the nearest hospital and who used hospitals with better quality measure performance were more likely to have timely follow-up outpatient visits after discharge. The association with using the nearest hospital was sensitive to the specifications of follow-up visits. In Aim 3, we found that patients varied greatly in their approach to choosing hospitals. Some patients had never actively considered using a different hospital, while others had done so either due to their personal priorities for healthcare or prior negative experiences at a hospital.

As rural hospitals consider how to best serve their communities, including patients more and less likely to bypass them, these findings provide insight into the potential benefits and drawbacks for patients of using the nearest hospital when possible. They also highlight the importance of providing high-quality care for all patients regardless of their ability or desire to bypass, as differences in quality of care contribute to healthcare inequality.