Quality of Care in Rural Hospitals

Abstract

To the Editor. —Keeler et al 1 concluded that the quality of care in smaller rural hospitals was substandard, possibly due to an inferior medical staff. The possibility was raised that small and rural hospitals should be closed. As a small hospital physician, I feel compelled to challenge the conclusions. The mindset of teaching hospitals is toward aggressive treatment rather than supportive care. The patients at small rural hospitals may be more likely to have do not resuscitate orders. It would be inappropriate for these patients to be admitted to an intensive care unit or given aggressive care, although this would raise a hospital's mortality rate and lower the explicit and implicit quality of care. A higher 30-day mortality rate may in these circumstances represent better, more humane quality of care. In the large urban centers, patients are more likely to be cared for by specialists (eg, cardiologists for myocardial