US Public Perceptions About Cancer Care Provided by Smaller Hospitals Associated With Large Hospitals Recognized for Specializing in Cancer Care

Over the past 5 years, smaller hospitals have developed formal relationships with larger hospitals at a historic rate, with more than 100 new mergers, acquisitions, and affiliations being filed each year in the United States.^1,2 Applying the brand of a larger hospital to smaller, affiliated hospitals has become commonplace.³ This brand sharing has the potential to influence patient decisions about where to pursue care, particularly for complex conditions such as cancer.⁴ However, the extent to which patients perceive the care at the smaller hospitals to be affected by affiliation is unclear. In an effort to understand patient expectations associated with brand sharing for complex cancer care at smaller hospitals, we surveyed a nationally representative sample in the United States.

An internet KnowledgePanel survey (GfK Group) was distributed across a nationally representative adult sample in November 2017.⁵ Respondents were asked to consider a smaller hospital developing a relationship (affiliation) with a larger hospital recognized for specializing in cancer care, and questioned regarding the impact of the affiliation on the smaller hospital (questionnaire available on request). To account for variable response rates across sociodemographic strata, results were weighted (using age, sex, race, region, metropolitan area, income, education, and home ownership) to mirror the US population and are reported with 95% confidence intervals (CIs). The study was approved by the Yale University Human Investigations Committee, which provided a waiver of written informed consent. Respondents were not compensated directly, but were periodically entered into raffles run by GfK group to encourage participation.

Overall 1010 (58.1%) of 1738 surveys were completed. There were 516 (51.6%) female respondents with a mean (SD) age of 47.6 (17.4) years; 713 (64.0%) were white, 128 (15.9%) Hispanic, 79 (11.8%) black, and 72 (8.3%) other (demographic table available on request).

Overall, 943 (94%) respondents felt that cancer care at a smaller hospital would improve after affiliating with a larger hospital specializing in cancer. A total of 131 (14%) respondents believed improvement would happen right away, 392 (39%) within 6 months, and 738 (73%) within a year. After affiliation, respondents expected physicians at the larger hospital to be involved considerably in the care of patients at the smaller hospital (Table 1). Most respondents (594 [60%]) believed physicians from the larger hospital were “often” or “always” involved in at least 1 of 5 potential areas of care integration. Specifically, 922 (92%) respondents expected surgeons from the larger hospital to operate at the smaller hospital, including 308 (32%) who felt this would take place “often” or “always” (Table 1).

Regarding the impact of affiliation on patient choice, 785 (77%) respondents indicated they would choose to have complex cancer surgery at a smaller hospital that was affiliated with a larger hospital over a smaller hospital without an affiliation. When asked about distinguishing aspects of the care provided by the smaller, affiliated hospital, 484 (47%) felt the care was more guideline compliant, 474 (47%) believed it was safer, and 368 (37%) felt it was more likely to be curative compared with a smaller hospital without an affiliation (Table 2).

The survey results illustrate both the perceived favorable impact (which is not uniform) and potential influence of hospital affiliations in the United States. There is a clear public expectation that physicians working at larger hospitals participate in the care of patients at smaller, affiliated hospitals (as opposed to simply providing smaller hospital physicians appointments at the larger hospital), yet there are some obvious geographic and temporal barriers that could limit this in practice. Understanding the perceived impact of affiliation on smaller hospitals is particularly relevant, because most US patients receive complex cancer care at smaller hospitals.⁶ It is the responsibility of the involved hospitals to understand patient expectations when the brand of a recognized cancer hospital is presented at a smaller hospital, and either comply with those expectations or clarify their advertising.

Corresponding Author: Daniel J. Boffa, MD, Section of Thoracic Surgery, Yale University School of Medicine, 330 Cedar St, BB 205, New Haven, CT 06520 (daniel.boffa@yale.edu).

Accepted for Publication: March 14, 2018.

Published Online: May 31, 2018. doi:10.1001/jamaoncol.2018.1400

Author Contributions: Drs Chiu and Boffa had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Chiu, Resio, Hoag, Blasberg, Boffa.

Drafting of the manuscript: Chiu, Blasberg, Boffa.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chiu, Hoag, Boffa.

Administrative, technical, or material support: Resio, White.

Study supervision: Hoag, Blasberg, Boffa.

Conflict of Interest Disclosures: None reported.