In-hospital mortality rates dropped by 33 percent at a hospital serving one of the highest Medicaid populations in the country after its 2016 merger with NYU Langone Health, showcasing how properly managed mergers can improve quality of care, a new study finds.
Published online in JAMA Network Open on January 6, 2022, the study found that in-hospital mortality at NYU Langone Hospital—Brooklyn, formerly Lutheran Medical Center, in the southeast Brooklyn community of Sunset Park declined from an average of 2.6 percent in the pre-merger period to 1.9 percent post-merger. The study also showed a 39 percent improvement on central line infections per 1,000 catheter days; a 33 percent improvement in catheter-associated urinary tract infections per 1,000 discharges; and a higher likelihood of patients recommending the hospital or giving it a top-tier ranking compared to before the merger.
“Our study shows that when a hospital merger has a comprehensive strategy, focuses on quality, and involves meaningful operational integration, outcomes can be significantly improved at the acquired hospital,” says lead study author Erwin C. Wang, MD, assistant professor in the Department of Medicine at NYU Grossman School of Medicine and medical director of the nurse practitioner service at NYU Langone Hospital—Brooklyn. “The vast majority of the existing research on hospital mergers finds that these transactions are likely strictly financially motivated and thus do not involve true operational integration and did not improve quality outcomes.”
A Contrast to Previous Studies
The current results stand in contrast to recent studies that found most mergers do not improve quality or safety—even when they involve high-quality acquirers. In these studies, overall mortality and readmission rates did not improve and patient experiences worsened. Additionally, many mergers demonstrated a lack of integration in management, culture, and data systems. However, researchers conclude that this was not the case with the NYU Langone experience.
“By focusing on improving quality, this merger led to an impressive shift in quality and safety metrics, most notably a significantly lower mortality rate,” says senior author, Bret J. Rudy, MD, senior vice president and chief of hospital operations at NYU Langone Hospital—Brooklyn. “Importantly, our results differ from the existing literature that has shown hospital consolidations have generally failed to improve quality,”
Following the acquisition, leadership at NYU Langone Hospital—Brooklyn focused on five areas to achieve strategic integration: clinical leadership integration; information technology transition; local ownership and accountability of quality outcomes; system-level goals with real-time, actionable analytics, through combined dashboards; and value-based, analytics-driven interventions.
Clinical Leadership Integration
Clinical leadership integration involved the following advances:
- implementing a leadership governance structure more typical of academic systems to reinforce accountability and dedication to quality, while ensuring local autonomy to manage specific operational challenges
- replacing physician leaders who had part-time hospital appointments with full-time, employed physicians
- establishing new service lines at NYU Langone Hospital—Brooklyn, including reconstructive breast surgery, spine surgery, robotic surgery, advanced endoscopy, and advanced bronchoscopy
Information Technology Transition
The information technology transition included the launch of a comprehensive electronic health record (EHR) and cost-accounting system integrated through dashboards with real-time analytics of clinical and operational performance.
Local Ownership and Accountability
Leadership encouraged local ownership and accountability of quality outcomes with the following initiatives:
- instituting quality committees and occurrence review committees to replace committees that involved part-time, voluntary clinical leaders
- setting post-merger meetings with employed, full-time clinical leadership that reviewed a broader number of cases and reinforced accountability
System-level goals were established using real-time, actionable analytics through combined dashboards. This enabled monitoring mortality rates in near-real time and identifying opportunities for closer leadership review.
Value-Based, Analytics-Driven Interventions
Projects were supported by information technology, including her-embedded decision support such as guideline-based blood transfusions. Additional projects targeted improvement opportunities such as hospital-acquired conditions (HACs).
How the Study Was Conducted
The research team used data taken from 122,348 patients in the pre-merger (September 1, 2010, to August 31, 2016) and 58,904 patients in the post-merger (September 1, 2016, to August 31, 2019) periods. The patients had an average age of 55 years, and more than 60 percent of those patients were female. The payer mix was largely governmental, and the admissions were more than 65 percent emergencies. Medicare and Medicaid accounted for 80 percent of insurance coverage.
The primary outcome metric was in-hospital mortality. Secondary outcome metrics were in-hospital readmissions; HACs including catheter-associated urinary tract infections and central line-associated bloodstream infections; and patient experience scores measured through Hospital Consumer Assessment of Healthcare, Providers, and Systems surveys. The researchers utilized two approaches to analyze pre- and post-merger outcomes: interrupted time series and statistical process control.
One study limitation is that while past research focused on the aggregate effect of mergers on quality, this study focused on only a single hospital. NYU Langone Health recently acquired another academic, community-based hospital, which may afford an opportunity to determine if these findings are replicable. Another limitation was that the study interventions were bundles, such that the researchers could not determine which components of the approach, EHR or integrated clinical operations, had the greatest impact on the improvements observed after the merger.
In addition to Dr. Rudy and Dr. Wang, the study’s other authors (all from NYU Langone Health) are Sonia Arnold, MBA; Simon A. Jones, PhD; Yan Zhang, MPH; Frank M. Volpicelli, MD; Joseph M. Weisstuch, MD; and Leora Horwitz, MD.