Abstract
Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation. To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent. In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy-eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020. Hospital mergers. The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries. A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, -2.825 to -0.685) percentage points greater at merged hospitals than at comparison hospitals (P < .001). This finding held up to 4 years postmerger (DID, -2.039 [95% CI, -3.388 to -0.691] percentage points; P = .003). Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were also observed at 5 years postmerger among stays for heart failure (DID, -0.756 [95% CI, -1.448 to -0.064] percentage points; P = .03), stroke (DID, -1.667 [95% CI, -3.050 to -0.283] percentage points; P = .02), and pneumonia (DID, -0.862 [95% CI, -1.681 to -0.042] percentage points; P = .04). These findings suggest that rural hospital mergers were associated with better mortality outcomes for AMI and several other conditions. This finding is important to enhancing rural health care and reducing urban-rural disparities in quality of care.
Highlights
More than one-third of US community hospitals are located in rural areas, serving as the principal source of care for 60 million people, nearly 20% of the US population.[1,2] For the past few decades, rural hospitals have faced declining populations, worsening economic conditions, and persistent shortages of clinicians,[3] putting them at greater risk of closure than their urban counterparts.[4,5,6,7] To avoid closure, merger and acquisition, hereafter referred to as merger, may be an option for sustaining rural hospitals and ensuring essential access to care for their communities.[8]
Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were observed at 5 years postmerger among stays for heart failure (DID, −0.756 [95% CI, −1.448 to −0.064] percentage points; P = .03), stroke (DID, −1.667 [95% CI, −3.050 to −0.283] percentage points; P = .02), and pneumonia (DID, −0.862 [95% CI, −1.681 to −0.042] percentage points; P = .04)
These findings suggest that rural hospital mergers were associated with better mortality outcomes for acute myocardial infarction (AMI) and several other conditions
Summary
More than one-third of US community hospitals are located in rural areas, serving as the principal source of care for 60 million people, nearly 20% of the US population.[1,2] For the past few decades, rural hospitals have faced declining populations, worsening economic conditions, and persistent shortages of clinicians,[3] putting them at greater risk of closure than their urban counterparts.[4,5,6,7] To avoid closure, merger and acquisition, hereafter referred to as merger, may be an option for sustaining rural hospitals and ensuring essential access to care for their communities.[8]. Mergers may enhance rural hospital survival, they may have effects on quality of care Prior studies on this topic tended to focus on urban hospitals, with the primary concern that consolidation could lead to increased market power. These studies were inconclusive on the association between hospital mergers and quality of care as measured by mortality, readmissions, complications, clinical processes, and patient experience.[11,12,13,14,15,16] To our knowledge, only 1 recent study, by O’Hanlon and colleagues,[17] examined quality of care along with access to care and financial performance after rural hospital affiliation with health systems. The authors found significant improvement in hospital operating margins after system affiliation but no difference in patient experience and 30-day hospital-wide all-cause readmissions.[17]
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