Mergers Associated With Improved Quality, Lower Mortality for Rural Hospitals

Rural hospitals are increasingly merging with other hospitals, and this trend is associated with better mortality outcomes for certain conditions, according to a new study in JAMA Network Open.

Rural hospitals have a number of challenges that put them at greater risk of closure than urban hospitals, which in turn reduces rural patients’ access to care and puts them at a greater risk of mortality.

“The number of mergers among rural hospitals has increased significantly since the mid-2000s, in parallel with the accelerating number of closures,” the authors wrote. “Although mergers may enhance rural hospital survival, they may also have effects on quality of care.”

To analyze changes in quality of care for patients at rural hospitals that merged, they compared the changes with rural hospitals that remained independent. They used multiple data sources to identify mergers between 2009 and 2016 and a difference-in-differences (DID) design to compare the changes in quality. Quality was measured using all-payer discharge from the 2008 to 2018 Healthcare Cost and Utilization Project State Inpatient Databases.

They reviewed discharges at 172 merged hospitals and 266 comparison hospitals during the premerger period. Baseline patient characteristics were comparable for age, sex, expected payer, community income, urban/rural location, number of chronic conditions, and travel distance. Patient baseline characteristics were also similar in the postmerger period.

The researchers analyzed in-hospital deaths for six medical conditions: acute myocardial infarction (AMI), heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture and pneumonia.

They found:

• Mortality rates for AMI fluctuated during the premerger period at merged hospitals, but declined from a high of 10.9% to 6.3% at one year postmerger
• By five years postmerger, AMI mortality was down to 4.3%
• Mortality rates for heart failure, stroke and pneumonia all steadily decreased
• Mortality rates for gastrointestinal hemorrhage and hip fracture remained stable for both merged hospitals and comparison hospitals
• Overall, the DID analysis found risk of mortality of all stays for the 6 conditions had a greater decrease at the merged hospitals than at comparison hospitals postmerger

The significantly improved mortality for patients with AMI at merged hospitals could be a result of the greater resources and support available from the larger system, the authors suggested. The volume of AMI stays increased at merged hospitals after the merger, and there is an inverse association between mortality and inpatient volumes.

The improvements in mortality for heart failure, stroke, and pneumonia occurred three to five years after the mergers. “This timeframe is consistent with research indicating that adoption of quality improvement approaches is complex and requires internal diffusion within given health care organizations prior to improved outcomes,” the authors noted.

In rural areas, heart failure and pneumonia are high-volume conditions. In addition, these areas have aging populations, and treating acute stroke is challenging, especially with reduced access to care, which has increased the risk of death for rural residents.

“These findings indicate that mergers of rural hospitals are not necessarily associated with adverse changes in the quality of care at these hospitals,” the authors concluded. “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.”