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Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates

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Abstract

Background

We define a “flagship hospital” as the largest academic hospital within a hospital referral region and a “flagship system” as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.

Objective

To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.

Design

A matched cohort study

Participants

The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.

Main Measures

30-day (primary) and 90-day (secondary) all-cause mortality.

Key Results

30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality.

Limitations

The study used claims-based data.

Conclusions

In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.

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Acknowledgements:

This research was supported by the National Institute on Aging (Grant # R01AG060928).

Author information

Authors and Affiliations

  1. Center for Outcomes Research, Children’s Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA

    Siddharth Jain DrPH, Joseph G. Reiter MS, Alexander S. Hill BS, Sean Hashemi BS & Jeffrey H. Silber MD, PhD

  2. The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA

    Paul R. Rosenbaum PhD, Omar I. Ramadan MD, MSc, Rebecca T. Brown MD, MPH, Rachel R. Kelz MD, MSCE, MBA, Lee A. Fleisher MD & Jeffrey H. Silber MD, PhD

  3. Department of Statistics and Data Science, The Wharton School of the University of Pennsylvania, Philadelphia, PA, USA

    Paul R. Rosenbaum PhD

  4. Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Omar I. Ramadan MD, MSc & Rachel R. Kelz MD, MSCE, MBA

  5. Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Rebecca T. Brown MD, MPH

  6. Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA

    Rebecca T. Brown MD, MPH

  7. Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Lee A. Fleisher MD

  8. Center for Perioperative Outcomes Research and Transformation, The University of Pennsylvania, Philadelphia, PA, USA

    Lee A. Fleisher MD

  9. The Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Jeffrey H. Silber MD, PhD

  10. Department of Health Care Management, The Wharton School of the University of Pennsylvania, Philadelphia, PA, USA

    Jeffrey H. Silber MD, PhD

Authors
  1. Siddharth Jain DrPH
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  2. Paul R. Rosenbaum PhD
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Correspondence to Siddharth Jain DrPH.

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Jain, S., Rosenbaum, P.R., Reiter, J.G. et al. Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates. J GEN INTERN MED 39, 902–911 (2024). https://doi.org/10.1007/s11606-023-08415-w

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