A growing number of rural hospitals — known as “critical-access hospitals” — are performing orthopedic surgeries, especially joint replacements. But because the staff at these hospitals is often inexperienced, patients who undergo surgery at these smaller facilities face a greater risk of complications, and even death.

Over the years, studies have shown that patients do better with surgery at a hospital that performs the procedure on a regular basis. Typically, this means larger, general hospitals and not rural hospitals.

When it comes to joint replacement surgery, the average rural hospital performed about 23 of the procedures in 2013. Meanwhile, general hospitals performed about 132 joint replacements during 2013. Hospitals that perform more than 100 joint replacements each year present the lowest risk of complications, according to reports.

A recent Wall Street Journal study (subscription required) of rural hospitals revealed that:

  • Between 2010 and 2013, patients undergoing orthopedic surgery at a rural hospital, including joint replacement, were 34 percent more likely to die within a month than patients having the same surgery at a general hospital.
  • In 2013, the 30-day mortality rate for joint replacements was about 9 per 1,000 at rural hospitals, while at general hospitals it was 5 in 1,000.
  • The orthopedic procedures being performed at rural hospitals are usually elective surgeries, which could be scheduled at a general facility with more experience.
  • Medicare-covered joint replacements at rural hospitals rose nearly 43 percent between 2008 and 2013, surpassing the growth of these services at general hospitals during the same period.

So why are rural hospitals performing more orthopedic surgeries? Various reasons have been given, including an increasing number of these hospitals merging with larger facilities.

But according to experts, the main reason for the increase is orthopedic surgeries is the financial incentives offered by Medicare.

Under a program implemented nearly 20 years ago, Medicare pays rural hospitals more than general hospitals for the same services, including surgeries. These higher payments were put in place to help ensure that rural hospitals stayed afloat and recovered more than their actual costs. Some in the health-care community are now suggesting these Medicare rules be changed.

Another distinction between rural and general hospitals is that critical-access facilities are not obligated to report their quality measures. This includes their rates of surgical complications. While some rural hospitals report this information voluntarily, most do not, giving would-be patients little chance of comparing their mortality rates with those at larger facilities.