By John Sittser
The pandemic has exposed the full scope of our nation’s healthcare challenges. Surges in patient volume coupled with a reduction in available staffing meant hospitals were routinely operating over capacity, leaving some regions without sufficient bed availability for weeks—and highlighting the consequences of our long-standing rural healthcare crisis.
As the conversation turns to rebuilding the resiliency of our healthcare system, disparities in care are top of mind for many organizations. The disproportionate impact of COVID-19 on racial and ethnic minority groups, as well as on rural and poor populations, has shown the extent of our healthcare accessibility gaps.
Counties with a high social vulnerability index—a measure that takes socioeconomic status and minority status into account, among other social determinants of health—experienced consistently higher death rates from COVID-19 than other counties. Data from the Centers for Disease Control and Prevention shows that Hispanic, Black, and American Indian/Alaskan Native people have been twice as likely to die from COVID-19 as white people.
In rural America, the COVID-19 mortality rate continues to exceed that of urban America. While part of this gap can be attributed to lower vaccination rates in rural communities, residents in rural areas are also more likely to be older, be poorer, and have more comorbidities.
Even before the pandemic, the rural-urban healthcare divide was well documented. In a 2019 survey of Medicare beneficiaries with one or more complex chronic conditions, researchers found that living in a rural area was associated with a 40% higher rate of preventable hospitalization, along with a 23% increase in mortality.
The access gap in rural communities
Healthcare disparities impact many disadvantaged populations, who are more likely to have poor health status in addition to limited access to healthcare services. A lack of income, limited medical transportation, and geographic location are three of the primary social determinants of health that impact healthcare accessibility. According to the American Hospital Association, transportation barriers, including long travel distances and the lack of a vehicle, are a leading cause of missed medical appointments for elderly patients.
Routine healthcare visits—including visits with specialists—are key to avoiding preventable hospitalizations and even reducing mortality rates. For patients with chronic conditions who had one or more primary care physician visits, researchers found that completing one or more specialist visits during a year was associated with a 15.9% reduction in preventable hospitalizations.
In rural areas of the country, however, specialists, hospitals, and even physicians are few and far between. According to the National Rural Health Association, 19.3% of Americans live in rural areas, which have an average of 13.1 physicians per 10,000 residents (compared to 31.2 in urban areas) and 30 specialists per 100,000 residents (compared to 263 in urban areas).
Since 2010, 138 rural hospitals have closed across the country. The Center for Healthcare Quality and Payment Reform estimates that 40% of the remaining rural hospitals are at risk of shutting their doors.
The impact of time and distance on emergency care
It can be difficult for many residents of suburban and urban areas to fully understand how geography can affect healthcare accessibility. For example, calling 911 for a patient with suspected stroke symptoms in Seattle, Washington, will likely result in the patient being rushed via ambulance to one of three receiving facilities within 10 minutes of their residence, presumably within the door-to-treatment window known as the “golden hour” of stroke care.
From there, doctors will order a CT scan of the patient’s brain and focus on either stopping the bleeding (for a hemorrhagic stroke) or dissolving or removing a blood clot (for an ischemic stroke). Time is of the essence, as fast treatment can mean the difference between permanent disability and significant recovery.
If a patient calls 911 with suspected stroke symptoms in a small town in the Midwestern U.S., however, it could take 34 minutes to reach a hospital, which might well be one of the 47% of the country’s rural hospitals with 25 or fewer acute care beds. These federally designated critical access hospitals (CAH) receive benefits, such as cost-based reimbursement for Medicare services, to help ensure their continued viability.
After the patient is stabilized at the hospital, they are likely to require transfer to a larger facility for continued treatment (96% of ischemic stroke patients are transferred from CAHs to a larger hospital to receive definitive care). The time required for interfacility emergent transfers can significantly impact outcomes and mortality rates. One study of almost 800,000 stroke patients found that the risk of death was 16% higher for patients in rural areas and 21% higher for patients in remote rural areas than for patients in urban areas.
While this example only addresses rural-urban disparities in stroke care, patients with all types of time-critical emergent conditions—from trauma to sepsis to severe heart attack—are more at risk in rural communities. Periods of crisis, such as the pandemic, exacerbate those risks.
The need for patient movement data
When the healthcare system at large is inundated with patients, wait times for emergent transfers rise precipitously. Patients in rural communities might require transfer to another facility because their condition calls for specialization or testing that the sending facility cannot offer, or because the sending facility does not have the capacity or expertise to provide the appropriate level of care.
As the omicron COVID-19 surge peaked in the fall of 2021, hospital bed availability fell to an all-time low in many parts of the country, resulting in increased wait times for patients needing a higher level of care. Many rural hospitals struggled to find beds for their patients in need, as the tertiary care hospitals in urban areas—which would normally receive their transfer patients—were already full.
While state and national leaders were aware of the hospital staffing shortage and care delays, they typically lacked the means to collect, quantify, or evaluate patient movement data. In most states, a lack of real-time data across the healthcare ecosystem rendered state governments and public health agencies unable to anticipate or deflect the impact of COVID-19 surges.
Unlike most states, the Kansas Department of Health and Environment (KDHE) collected and monitored statewide disease activity and resource utilization through a web-based patient movement platform (Motient’s Mission Control), which tracked facility capacity status along with the origin, presumptive diagnosis, acuity, and destination of transferred patients. In 2021, the platform was used by 122 Kansas hospitals to facilitate more than 5,000 patient transfers to 209 destination facilities, some of which were outside of the state. In September 2021, patient transfer wait times continued to rise, and the number of patients who died awaiting transfer increased five-fold compared to the previous three months.
KDHE used this patient movement data to help educate state policymakers on the capacity limits of the ecosystem, objectively demonstrating the need for action. Policymakers reviewed patient movement data, along with other input, and instituted a state of emergency for the second time during the pandemic. The data also helped leaders justify and enact mitigations to expand hospital and long-term care center capacity, including engaging the Federal Emergency Management Agency and the Veterans Health Administration to provide short-term medical treatment for transferred patients.
Health equity begins with naming the problem
Without widespread insight into patient movement trends, it will be challenging to address many of the healthcare disparities between rural and urban communities. By examining how care needs and services are balanced across a regional ecosystem, healthcare leaders can identify opportunities to increase care access and improve performance efficiency.
For example, patient movement data might indicate that a cardiac catheterization lab, which provides a variety of diagnostic and interventional cardiac procedures, might be well placed at the epicenter of five rural hospitals that routinely transfer cardiac patients to tertiary care facilities. After charting macro trends like transport vendor availability, a healthcare organization might decide to partner with other facilities to open its own ambulance service.
By taking a more granular look at actual patient movement data in real time, rural hospitals—and the states that support them—can quantify the exact nature of the resource utilization problems they face. From there, they can begin to make informed choices that move us toward the goal of health equity for all.
John Sittser is the director of analytics and business intelligence at Motient, a patient movement platform that helps ensure quality care and value in interfacility patient transfers. He can be reached at email@example.com.