Health Affairs: Clusters of hospitals may improve coordination

As more and more hospitals begin to join hospital systems and “cluster,” coordinated care has improved, according to a report published in the September issue of Health Affairs. In fact, researchers offered that these systems can help to restructure health services in the upcoming years.

“Since the 1990s, rapid consolidation in the hospital sector has resulted in the vast majority of hospitals joining systems that already had a considerable presence within their markets,” Roice D. Luke, PhD, professor at the Virginia Commonwealth University in Richmond, Va., and colleagues wrote. “We refer to these important local and regional systems as 'clusters.'”

During the current study, Luke and colleagues evaluated within-cluster concentrations of high-risk cases for seven surgical procedures to determine whether hospital clusters have taken measurable steps at improving quality of care. As of 2009, 70 percent of acute care hospitals in urban markets joined multihospital systems, up from the 44 percent reported in 1989. Of these hospitals, 79 percent were in urban clusters, up from 56 percent in 1989.

“Clusters dominate their markets; they have the capacity to integrate services and redistribute capacities; and many continue to absorb into their systems other provider organizations, including specialty hospitals and ambulatory surgery centers,” the authors wrote.

Luke et al assessed the degree to which study hospitals—clustered or nonclustered—met Leapfrog Group volume standards. The researchers reported that only 10 percent of hospitals reached or exceeded volume standard and 50 percent failed to reach the standard.

“In general, the numbers present a mixed picture. On the one hand, a considerable number of hospitals are not performing any of the high-risk procedures, which means that patients are being referred to facilities that presumably are equipped to perform them,” the authors wrote. “On the other hand, the numbers of facilities performing the procedures but not meeting the standards are high for most of the procedure categories. There thus remains room for improvement by concentrating services in high-volume facilities.”

For lead hospitals, there were an increased number of procedures performed per cluster. For example, the averages ranged from 59 percent for esophagectomy to 87 percent for aortic valve replacement. These hospitals also experienced significant changes in cluster shares for five of the seven procedures. However, changes were slim in two procedures that had the largest numbers of admissions: CABG and PCI.

“This may suggest that efforts to concentrate services within such relatively high-volume and lucrative procedure categories might be difficult to achieve, especially given the financial and clinical impacts that might be produced by shifts in service capacities for facilities that lost cases in these areas,” Luke and colleagues wrote.

The authors said that the study raises an important question: Should policy shift from focusing on individual hospital toward clusters? Luke and colleagues wrote that there are two sides; they said that clusters are more able to position themselves administratively to make decisions. “They [clusters] are emerging as the accountable entities that ultimately will direct members’ responses to policy initiatives.

“[T]his study draws attention to the potential that clusters offer for coordinating services across hospitals and other providers locally,” Luke et al concluded. “As a major new and powerful organizational form in this country and, interestingly, internationally, the clusters could play a key role in restructuring health services in the years to come.”