Full-Integration Hospital Mergers Can Improve Quality of Care, Study Finds

A hospital merger in New York City decreased mortality, improved HCAHPS scores, and reduced hospital-acquired conditions.

A full-integration approach to a hospital merger was associated with quality improvements including a reduction in mortality rates, a recent research article says.

Earlier research has shown that hospital consolidations have more than doubled since 2009. Other earlier research has found hospital mergers can have a negative impact on quality, including increased mortality rates associated with a reduction in hospital competition.

The recent research, which was published by JAMA Network Open, highlights the acquisition of Lutheran Medical Center by the academic health system NYU Langone Health in 2016. Lutheran Medical Center, which was a 450-bed safety net hospital, was renamed NYU Langone Hospital—Brooklyn.

The study examined data before the merger from September 2010 to August 2016 and after the merger from September 2016 to August 2019. The primary focus of the research was in-hospital mortality, but the study also examined 30-day readmissions, patient experience, and hospital-acquired conditions.

NYU Langone Health's full-integration approach to the merger had five facets, the study's co-authors wrote: "(1) early administrative and clinical leadership integration with the academic health system; (2) rapid transition to the academic health system electronic health record; (3) local ownership of quality metrics; (4) system-level goals with real-time actionable analytics through combined dashboards; and (5) implementation of value-based and other analytic-driven interventions."

The study features several key data points for NYU Langone Hospital—Brooklyn.

• From before the merger to after the merger, unadjusted mortality decreased 0.71% on an absolute basis and 27% on a relative basis.
   
• From before the merger to after the merger, risk-adjusted mortality decreased 0.95% on an absolute basis and 33% on a relative basis.
   
• Three years after the merger, there was significant improvement in HCAHPS survey performance. For example, more patients registered 9 or 10 ratings to the question, "Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?"
   
• There were improvements in hospital-acquired conditions. There was a reduction in central line infections per 1,000 catheter days and a reduction in catheter-associated urinary tract infections per 1,000 discharges.
   
• There was no significant change in 30-day readmissions.

"These results suggest that a full clinical and operational integration approach to a hospital merger may improve outcomes as measured by quality and safety metrics, including mortality rates," the study's co-authors wrote.

Keys to success

The merger was not driven by financial factors, which may explain the positive impact on quality, the study's co-authors wrote. "The goal of the merger was not revenue-driven; this uncommon full-integration approach was designed and executed to improve quality."

NYU Langone Health was committed to a value-driven approach to full integration, which included a common governance structure and a common electronic health record and cost-accounting system, the study's co-authors wrote.

"This focus on robust integration was balanced with identification of local opportunities, implementation of site-specific quality improvement interventions, and a systemwide adoption of some of these novel approaches. These innovations included nurse-driven and EHR-supported programs to reduce unnecessary urinary catheterization and, subsequently, [catheter-associated urinary tract infections]; physician-led root cause analyses and occurrence reviews; and multidisciplinary workgroups to reduce the frequency and duration of hospitalization for high users of care," they wrote.

The study's results indicate that hospital mergers can achieve improvements in quality, the researchers wrote. "This study of a system merger with a safety net hospital found that a full-integration approach to hospital consolidation was associated with improvement in quality outcomes. Despite evidence that mergers usually reduce quality, we found that strategic consolidations can be associated with substantially improved quality when performed effectively."