Q&A: Road to improving intensive care in rural areas

Key takeaways:

• Urban ICUs have 2.8 beds per 10,000 people, whereas rural ICUs only have 1.7 beds per 10,000 people.
• Hybrid ICU model adoption is a possible solution for the intensive care crisis in rural areas.

Rural area residents in need of medical attention might not be able to get the care they require due to the current intensive care crisis in these areas, according to a paper published in The Lancet Respiratory Medicine.

In this paper, Hao Yu, PhD, associate professor of population medicine at Harvard Pilgrim Health Care Institute, and colleagues point out that rural hospital closures have negatively impacted ICU capacity in these areas. Urban ICUs have 2.8 beds per 10,000 people, whereas rural ICUs only have 1.7 beds per 10,000 people.

Further, low socioeconomic status is more common in rural areas, and as Healio previously reported, hospitalized patients with various pulmonary conditions living in low vs. high socioeconomic status areas face a heightened likelihood for 30-day mortality and readmission.

Healio spoke with Yu to learn more about the disparities between urban and rural living, the reasons behind rural hospital closures and solutions for sustainable care provision in rural areas.

Healio: What are some common disparities between urban and rural living?

Yu: Prior studies have shown substantial differences in health care outcomes between urban and rural areas in terms of access to and utilization of emergency care, intensive care, preventive care, and cancer screenings and diagnostics. Additionally, rural areas have higher rates of mortality compared with their urban counterparts.

Physician shortages in rural areas also make it harder to get access to health care, especially for specialized medical care. In some cases, rural residents must drive for hours to find the nearest physician.

Healio: Since the COVID-19 pandemic, around how many rural hospitals have closed? What was the closure rate of these hospitals before the pandemic?

Yu: Around 35 rural hospitals have closed since the pandemic’s onset in 2020, bringing the total number of hospital closure during the past two decades (since 2005) to 195.

Healio: Why are these hospitals closing? What role does physician burnout have in these closures?

Yu: The reasons for hospital closure are multifactorial including low patient volumes, high financial pressures, physician shortages and poor reimbursement. Physician burnout is also a factor, especially since the pandemic’s onset has driven many physicians to leave clinical practice.

Prior research found that approximately one in five physicians considered exiting the workforce during the pandemic. With such a high turnover, physician shortage areas are most likely expanding.

Healio: What are some of the consequences of reduced intensive care in rural areas for residents?

Yu: Reduced intensive care has detrimental effects on rural residents’ access to lifesaving medical care, for example, leading to longer ICU transfer time. Since previous studies have shown that ICU transfer time is one of the greatest predictors of mortality among critically ill patients, health outcomes are expected to deteriorate (eg, higher mortality) in those rural areas with reduced ICU care.

Healio: Are these reductions in care having any impact on the physicians themselves?

Yu: Yes, hospital closures can have substantial economic impacts by reducing jobs and wages in the surrounding area. Furthermore, after a hospital closure, physicians are likely to leave the area as well, worsening health workforce shortages.

Healio: You outline two solutions for sustainable care provision in rural areas. What are these solutions, and what data are there to back them up?

Yu: We identify the need for tapping recent technological advancement to help support rural intensive care through hybrid ICU models, where intensive care physicians at larger medical centers can provide support to those in rural community hospitals. Through remote patient monitoring, remote nursing and improved telemedicine reimbursement, hybrid ICUs can bolster rural intensive care capacity. A recent systematic review and meta-analysis confirmed the significant effects of hybrid ICUs on reducing both mortality and length of stay. Since the start of the COVID-19 pandemic, hybrid ICU interventions have also increased staff comfort with treating complicated critical conditions, improved adherence rates to ICU best practices, and benefited hospital financial performance.

To finance hybrid ICUs, we discuss a multipronged approach that retains in-hospital, intensive care physicians through models such as Global Budgets where rural hospitals can prioritize clinical services that are in-demand by local community. The implementation of global budgeting among rural hospitals in Maryland has reduced Medicare expenditures in that state.

Healio: What is the Consolidated Appropriations Act of 2021? How can this policy be improved/updated to help with the intensive care crisis?

Yu: The Consolidated Appropriations Act of 2021 created rural emergency hospitals, which free up cash-strapped hospitals to convert their inpatient services to only support emergency care and select outpatient services. While this may improve access to emergency care in hospitals that are otherwise closing, it does not support intensive care in these areas. We suggest that Congress take further actions to bolster intensive care in rural areas by supporting hybrid ICUs and advancements in alternate payment delivery models.

Healio: What can policymakers do to support rural intensive care? How can clinicians advocate for this care?

Yu: Supporting rural intensive care needs joint actions by federal- and state-level policymakers. For example, as indicated above, Congress needs to consider legislation to prevent rural intensive care from further deterioration. State-level policymakers may want to adopt new technological advancements, such as hybrid ICU models, and implement alternative financing models, such as global budgets.

Finally, I would also like to point out two facts. First, the current intensive care crisis in rural areas is multifaceted and requires a comprehensive solution. For example, reducing uninsured populations though the Affordable Care Act Medicaid expansion and increasing the health workforce are well-studied solutions for sustainable care provision in rural areas.

Second, improving rural intensive care is a persistent challenge in the U.S. and other countries as well. Clinicians can advocate for rural intensive care in three ways:

1. to summarize and disseminate best practice of improving rural intensive care both within and outside the U.S.;
2. to engage in policy discussions with decisionmakers at community, state and federal levels; and
3. to spearhead experimental efforts to preserve and strengthen intensive care at their communities.

Improving rural intensive care is no easy task. Nonetheless, persistent efforts by researchers, advocates and policymakers can definitely preserve and strengthen this type of essential care in rural America.

For more information:

Hao Yu, PhD, can be reached at hao_yu@hphci.harvard.edu.

References:

• New analysis offers policy solutions for intensive care crisis in rural America. https://www.eurekalert.org/news-releases/1038186. Published March 19, 2024. Accessed March 20, 2024.
• Ramesh T, et al. Lancet Respir Med. 2024;doi:10.1016/S2213-2600(24)00031-6.