United States rural hospital quality in the Hospital Compare database-Accounting for hospital characteristics

Background: Rural hospitals in the United States have demonstrated lower adherence to evidence based guidelines than their urban counterparts in national public reporting initiatives. We compared the quality of rural hospitals participating in a public reporting initiative to that of their urban counterparts using Hospital Compare, a new national database containing process measures. Methods: Cross-sectional analyses of hospitals participating in Hospital Compare in 2005, evaluating percent adherence to guidelines for 10 processes of care for acute myocardial infarction (AMI), heart failure (HF), and community-acquired pneumonia (CAP) using multivariable linear regression analyses. Results: Participating rural hospitals demonstrated lower adherence to evidence based guidelines in MI and HF quality measures (p < 0.05) and higher adherence to prescribing antibiotics in a timely manner in CAP (p < 0.05). Differences increased with bed size (F test for linear trend, p < 0.05). After adjustment, the trends demonstrating lower adherence persisted in 6 AMI and HF measures and higher adherence in 1 CAP measure in spite of a disproportionate number of drop-outs among lower performing urban hospitals. Conclusions: Participating rural hospitals had lower performance than their urban counterparts. As the rural/urban quality gap varies by condition, bed size, and participation, we recommend comparing performance across a wide variety of condition-specific measures to enable targeted quality improvement.