In Reply: Dr Moscovice and Ms Casey appropriately highlight their ongoing work tracking quality at CAHs1; this work is essential to helping CAHs improve the care they provide. Our work adds to theirs by placing CAHs in a larger context, comparing them with other acute care hospitals in the United States, and increasing awareness about the unique challenges they face.
Moscovice and Casey, as well as Dr Westfall and colleagues, bring up important analytic points. We concur that an unadjusted comparison with large, urban teaching hospitals is not appropriate. For that reason, our analytic approach adjusted for clinical volume, location, and teaching status, among other factors. We also accounted for hospice use, which differs between CAHs and non-CAHs. The fact that mortality differences persisted after accounting for these dissimilarities suggests that additional efforts are needed to improve care at CAHs. We also agree that nontransferred patients may be older and sicker than those who are transferred, and our finding that the difference between CAHs and non-CAHs widened when we excluded transferred patients supports this. Transfers that originate from the ED of a CAH are not counted toward that hospital's performance, either in our analysis or by CMS for public reporting, and we agree that this should be explored further. Appropriate transfer from an ED could be a useful quality metric for CAHs and other small hospitals.