Obtaining meaningful information from statistically valid and reliable measures of the quality of care for disease-specific care provided in small rural hospitals is limited by small numbers of cases and different definitive care capacities. An alternative approach may be to aggregate and analyze patient services that reflect more generalized care processes. Purpose: To evaluate the applicability of intensive care unit (ICU) utilization and interhospital transfers as potential indicators of quality in rural hospitals. Methods: Secondary data analysis of ICU utilization and interhospital transfer practices in Iowa?s Critical Access (CAH), rural, rural referral, and urban hospitals. Findings: Rural hospitals have fewer resources, provide a more limited range of definitive care services, and rely to a greater extent on transferring patients to other hospitals capable of providing the required definitive care. Examining ICU utilization and interhospital transfer patterns we found (1) that lower percentages of patients receive ICU care in smaller facilities; (2) higher transfer rates for both ICU and non-ICU patients in CAH hospitals; (3) shorter average lengths of stay for ICU patients from smaller hospitals who were transferred; and (4) lower mortality rates for CAH and rural hospital ICU patients. Conclusions: Examining ICU utilization and interhospital transfer patterns offers potential insights into rural hospital quality measurement and comparisons.