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Mortality rates higher in affiliates, compared with top-ranked hospitals

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Beyond the brand: Cancer care in affiliate hospitals

Network affiliations with top-ranked hospitals could help expand access to high-quality cancer care and reduce travel times for patients who live too far away to access the top-ranked hospital itself. However, this study shows that the outcomes and quality of the flagship hospital do not necessarily translate to the affiliate hospitals in the network.

While affiliate hospitals are likely to deal with smaller numbers of complex patients and are less likely to be teaching hospitals, they do offer a way to potentially leverage their affiliation with top-ranked hospitals to improve the overall quality of care for cancer patients. The challenge is to work out how best to do this and to identify which patients are likely to do just as well at an affiliate hospital and which patients will be optimally treated at the flagship hospital.

Lesly A. Dossett, MD, MPH, is from the department of surgery at the University of Michigan, Ann Arbor. These comments are adapted from an accompanying editorial (JAMA Netw Open. 2019 Apr 12. doi:10.1001/jamanetworkopen.2019.1910). No conflicts of interest were reported.



The sharing of a top-ranked cancer hospital brand across affiliate hospitals doesn’t necessarily guarantee the same quality of care, a new study suggests.

In a paper published in JAMA Network Open, researchers presented the outcomes of a cross-sectional study of 29,228 patients aged over 65 years who underwent complex cancer surgery at either 59 top-ranked hospitals or 343 affiliated hospitals.

The researchers saw a significant 40% higher 90-day mortality rate among patients who underwent complex cancer surgery at one of the affiliate hospitals, compared with those who were treated at the top-ranked hospitals (P less than .001), even after adjusting for factors such as age, comorbidity score, procedure type, and admission type.

“This is not entirely surprising, as affiliated hospitals are generally smaller, less likely to be teaching hospitals, and perform complex surgical procedures with less frequency (lower volume) when compared with top-ranked hospitals,” wrote Jessica R. Hoag, PhD, from the department of surgery at Yale University, New Haven, Conn., and her coauthors. However, including hospital characteristics in the models attenuated but did not eliminate the differences in mortality rates between top-ranked and affiliate hospitals.

The difference in 90-day mortality was particularly evident for gastrectomy, where there was a 100% higher 90-day mortality rate in affiliate hospitals, compared with top-ranked hospitals (P less than .001). The mortality rate for pancreaticoduodenectomy was 59% higher in affiliate hospitals, compared with top-ranked hospitals (P = .009); for colectomy it was 32% higher (P = .001), and for lobectomy it was 34% higher (P = .03).

The only procedure where the mortality rate was not statistically significantly different between top-ranked and affiliate hospitals was esophagectomy (odds ratio, 1.48; P = .06).

When the authors looked at standardized mortality ratios for the top-ranked and affiliate hospitals, they found that 41 of the 49 top-ranked hospitals had lower mortality ratios than their collective affiliates. In 37 cases, the difference in standardized mortality ratios between the top-ranked hospital and its affiliates was statistically significant.

Overall, 39 of the 49 top-ranked hospitals had better standardized mortality ratios than the national average, compared with 17 of the affiliated networks.

The authors wrote that their findings were important because previous studies showed affiliation status played a significant role in which hospital patients choose for their treatment.

“As a result, there is cause for concern that a proportion of the U.S. public could misinterpret brand sharing as indicating equivalent care,” they wrote, suggesting that one way to reduce mortality might therefore be to direct patients with the most risky and complex surgical requirements to top-ranked hospitals rather than affiliates, although acknowledged this might be challenging to implement.

One author reported receiving funding from the Centers for Medicare & Medicaid Services, one reported advisory board and steering committee positions with the private medical sector, and one reported receiving nonfinancial support from private industry outside the submitted work. No other conflicts of interest were reported.

SOURCE: Hoag JR et al. JAMA Netw Open. 2019 Apr 12. doi: 10.1001/jamanetworkopen.2019.1912.

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