Rural hospitals that merge with larger health systems are linked to improved mortality outcomes for conditions such as acute myocardial infarction (AMI), stroke, and pneumonia, when compared to facilities that remained independent, according to a new study in JAMA Network Open.

Radio Advisory: The dire state of rural health care

JAMA study details

For the study, researchers from the Agency for Healthcare Research and Quality (AHRQ) and IBM Watson Health conducted a case-control analysis to identify changes in outcomes for patients discharged from rural hospitals before and after they merged with larger health systems. Those outcomes were compared with 266 hospitals that remained independent.

For the study, the researchers looked at the mortality rates for six health conditions, as well as the rate of complications after scheduled procedures. The researchers focused on data from 2009 to 2016. According to the study, baseline patient characteristics for medical and surgical stays were similar for merged hospitals and comparison hospitals that were not involved in a merger.

Specifically, researchers measured the rate of in-hospital deaths for acute myocardial infarction (AMI), heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia. To track those mortality rates, the researchers used all-payer discharge data from the 2008 to 2018 HCUP State Inpatient Databases (SID) to identify in-hospital stays that met the denominator specifications for medical mortality Inpatient Quality Indicators (IQIs). 

Meanwhile, the researchers measured the rate of complications—including hemorrhage or hematoma, respiratory failure, pulmonary embolism or deep vein thrombosis, and sepsis—that occurred during or after scheduled surgeries by using AHRQ Patient Safety Indicators (PSIs). 

Key findings

According to researchers, the annual inpatient mortality rate for AMI decreased from 9.4% to 5% for merged hospitals over the course of the study period. In comparison, independent facilities experienced a decrease in inpatient AMI mortality from 7.9% to 6.3% during the period studied.

Meanwhile, the researchers found that mortality rates for heart failure, stroke, and pneumonia improved at merged hospitals, although those improvements generally did not present until three to five years post-merger. Mortality rates remained stable for gastrointestinal hemorrhage and hip fracture for both merged and comparison hospitals, while complications following scheduled surgical procedures decreased for both merged and comparison hospitals.

The researchers said the findings "indicate that mergers of rural hospitals are not necessarily associated with adverse changes in the quality of care at these hospitals," as was suggested by a previous AHRQ study, Modern Healthcare reports. They added, "Mergers may enable rural hospitals to improve quality of care through access to needed financial, clinical, and technological resources, which is important to enhancing rural health and reducing urban-rural disparities in quality."

Expert opinions and critics' perspective

According to Modern Healthcare, the findings "add a new dimension to the debate over the benefits and potential harms of hospital consolidation."

Currently, Modern Healthcare reports, more than 33% of community hospitals in the nation are based in rural locations, serving an estimated 60 million people—but more than 100 rural hospitals have closed between January 2013 and February 2020, largely because of decreasing patient volume and staffing challenges.

In response, proponents of consolidation see mergers and acquisitions as a means to improve both financial and health outcomes for struggling rural hospitals. For instance, the American Hospital Association historically has advocated for hospital mergers and acquisitions, stating that they lower health care costs and improve care quality, Modern Healthcare reports.

However, critics argue that mergers can lead to less competition, reduced health care access, and higher medical costs—and have no significant improvement on care quality. (Johnson, Modern Healthcare, 9/20; May et al., American Health Association, 8/16; Jiang et al., JAMA Network Open, 9/20)