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Rural hospitals report improved mortality outcomes following a merger, JAMA says

A new study published in JAMA Open Network found that mergers of rural hospitals into larger health systems may improve mortality outcomes.

Researchers from Agency for Healthcare Research and Quality (AHRQ) and IBM Watson Health assessed in a case-control study the changes in inpatient quality of care for rural hospitals that merged or were acquired compared with rural hospitals that remained independent. 172 merged hospital and 266 comparison hospitals were analyzed using data from 2009 to 2016.

The study found decreases in mortality after the merger for conditions like acute myocardial infarction (AMI), heart failure, stroke and pneumonia. In-hospital deaths were measured using all-payer discharge data from the 2008 to 2018 HCUP State Inpatient Databases (SID) to identify inpatient stays that met denominator specifications for the Agency for Healthcare Research and Quality’s (AHRQ) medical mortality Inpatient Quality Indicators (IQIs). For example, the annual AMI mortality rate decreased from between 7.8% and 10.9% premerger to 4.3% post-merger.

The study attributed the decrease in part to increased technology and expertise from the larger health system. Overall, the study suggests that rural hospital mergers are associated with quality improvement and enable hospitals increased access to financial, clinical, and technological resources which may reduce urban-rural disparities in quality.

This study is particularly relevant given the recent Executive Order issued by President Biden which signaled the Administration’s intent to focus antitrust enforcement resources on healthcare generally and on hospital consolidation, in particular. In the accompanying Fact Sheet, the White House concluded “[h]ospital consolidation has left many areas, especially rural communities, without good options for convenient and affordable healthcare service.” 

When it comes to balancing access, prices, competition, quality of care and consumer needs, the study and its findings are likely to get significant attention from state and federal policymakers as they consider new guidelines for enforcement.  For community leaders who are considering the best approach for their hometown hospital, this sophisticated analysis will be an important tool for both deliberations and their communication strategy to key community stakeholders.  Finally, it isn’t uncommon for hospital sale transactions to include a wide range of operating and investment covenants that a buyer agrees to make for the community hospital post-close. 

This study can help guide these discussions and provide some objective data points for the parties to consider. Waller serves as hospital and board counsel to community and safety-net hospitals throughout the country. 


Jesse Neil
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Ellie Martin
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