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Member Research & Reports

Member Research & Reports

Michigan Research: Small, Rural Hospitals May be Safer for Common Operations

They may be in small towns. They may only have a couple of surgeons. But for common operations, they may be safer and less expensive than their larger cousins, a new study finds.

“They” are critical access hospitals – a special class of hospital that is the closest option for tens of millions of Americans living in rural areas. And according to new findings published in the Journal of the American Medical Association, having surgery at one of them may be a better bet for most relatively healthy patients than traveling to a suburban or city hospital.

Justin Dimick
[Photo: Dr. Justin Dimick]

A University of Michigan-led team carried out the analysis of data from 1.6 million hospital stays for four common operations: gallbladder removal, colon surgery, hernia repair, and appendectomy. They compared what happened to patients covered by Medicare who had their operations at 828 critical access hospitals with data from patients treated at more than 3,600 larger hospitals.

The analysis yielded several surprises: 


Patients who had four common operations at critical access hospitals had a lower chance of complications, and a nearly equal chance of dying, compared with patients who had the same operations at larger hospitals in suburban and urban areas.

Critical eye on critical access

The findings are timely because of a current debate over whether to change the national policies that designate critical access hospitals, and determine how much they get paid for medical and surgical services. Hundreds are these hospitals are in danger of closing, threatening local access to care for millions of Americans.

Currently, the Medicare system essentially subsidizes them by paying them slightly more than the total cost of care, in order to ensure they can stay financially afloat to serve rural areas. Even still, dozens have closed in recent years.

Recent studies of common medical conditions like heart attacks and pneumonia at critical access hospitals have raised questions about how well they care for patients with these conditions. The new study is the first comprehensive look at the surgical care they provide.

“From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care,” says Dr. Andrew Ibrahim, first author of the new study and a VA/Robert Wood Johnson Clinical Scholar at U-M.

Ibrahim and senior author Dr. Justin Dimick, worked on the study with Dr. Tyler Hughes, one of two surgeons at the critical access McPherson Hospital in McPherson, KS and a director of the American Board of Surgery.

Says Dr. Hughes, “The goal of the rural surgeon is best care nearest home. Data to assure that the care in rural centers is both safe and cost effective is critical in the decisions the profession faces in providing care to the 20 percent of the U.S. population living in truly rural environments.  This study gives credence to what rural surgeons long suspected — that well-done rural surgery is safe and cost effective.” Hughes helped the U-M team understand the triage process that surgeons at critical access hospitals use to decide whether to take a case or refer the patient to a larger center.

Says Dr. Dimick, “For many years, surgeons have debated whether we should concentrate surgery in a subset of our larger hospitals. The downside of this approach is that patients have to travel far from home for surgery, especially those living in remote areas. While it may make sense to travel to a higher volume hospital for a few of the most complex operations, this study shows that having surgery locally is safe for many of our most common surgical procedures.” Dr. Dimick is a professor of surgery and associate professor of health management and policy in the School of Public Health. Dr. Dimick also leads the Center for Healthcare Outcomes and Policy at U-M.

For information, click here.