Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals

JAMA Netw Open. 2021 Sep 1;4(9):e2124662. doi: 10.1001/jamanetworkopen.2021.24662.


Importance: Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation.

Objectives: To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent.

Design, setting, and participants: 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.

Exposures: Hospital mergers.

Main outcomes and measures: 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.

Results: 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).

Conclusions and relevance: 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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Case-Control Studies
  • Databases, Factual
  • Diagnosis-Related Groups / standards
  • Diagnosis-Related Groups / statistics & numerical data*
  • Female
  • Health Care Costs / statistics & numerical data
  • Health Care Surveys
  • Health Facility Merger / standards
  • Health Facility Merger / statistics & numerical data*
  • Hospital Mortality
  • Hospitals, Rural / standards
  • Hospitals, Rural / statistics & numerical data*
  • Humans
  • Inpatients / statistics & numerical data*
  • Linear Models
  • Male
  • Middle Aged
  • Myocardial Infarction / mortality
  • Patient Discharge / statistics & numerical data
  • Quality of Health Care / statistics & numerical data*
  • United States