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

Abstract

This survey study examines patient expectations about cancer care provided by smaller hospitals associated with larger 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.

Methods

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.

Results

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).

Table 1. Perceived Mechanisms by Which Small Hospitals Improve After Affiliation With a Larger Hospital in a Nationally Representative Sample of 1010 Participants^a.

How Often Do You Think Each of the Following Things Will Happen When a Small Hospital Joins in a Relationship With a Larger, Top-ranked Cancer Hospital?	Respondents, No. (%) [95% CI]b
	Never	Sometimes	Oftenc	Alwaysc
Complex surgery at the smaller hospital is performed by surgeons who come from the larger hospital.	81 (8.1) [6.3-9.9]	614 (59.9) [56.7-63.0]	265 (26.5) [23.6-29.3]	43 (5.0) [3.5-6.5]
Doctors at the larger hospital hear about you and your cancer from the smaller hospital.	159 (15.3) [13.0-17.6]	567 (57.3) [54.1-60.5]	206 (20.2) [17.6-22.8]	62 (6.5) [4.9-8.2]
Doctors at the larger hospital tell the doctors at the smaller hospital how to treat you.	148 (14.9) [12.6-17.2]	613 (59.6) [56.4-62.8]	196 (19.5) [16.9-22.1]	47 (5.5) [3.9-7.1]
If you have a complication after surgery at the smaller hospital you will be transferred to the larger hospital.	45 (4.5) [3.2-5.9]	603 (58.5) [55.3-61.7]	277 (27.6) [24.7-30.4]	78 (8.8) [6.9-10.7]
If you are sent home after surgery at the smaller hospital, and need to come back into the hospital for a complication, you will be admitted to the larger hospital.	94 (9.6) [7.7-11.6]	707 (68.4) [65.4-71.5]	156 (15.9) [13.5-18.2]	47 (5.6) [4.0-7.2]

Abbreviation: NA, not applicable.

^aSurvey questions were developed using focus groups and pilot surveys prior to the final study distribution. To achieve a nationally representative sample, the survey was repeatedly distributed using a probability-based sampling method to mirror the US population until a minimum of 1000 surveys were completed. A total of 1738 were distributed for a response rate of 58.1%. Sixteen surveys were excluded because they were incomplete.

^bTo account for variable response rates across sociodemographic strata, survey responses were weighted (age, sex, race/Hispanic ethnicity, education, region, household income, home ownership status, and residence in a metropolitan area) to maintain the sociodemographic profile of the US population. For each question, the proportion of respondents choosing not to answer was less than 2% (nonresponses not shown, therefore row total may not equal 100%).

^cIn all, 594 (59.9%) respondents chose “often” or “always” for at least 1 of the 5 previously asked questions listed in table regarding care integration (95% CI, 56.8-63.1). Because respondents tended to vary their responses across the questions in this table (did not choose the same frequency for each care element), the prevalence of respondents that chose “often” or “always” for at least 1 of the questions was higher than the prevalence in any individual question.

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).

Table 2. Perceived Differences in Surgical Processes and Outcomes at Small Hospitals According to Affiliation Status in a Nationally Representative Sample of 1010 Participants^a.

Which (if Any) Are Different Between the 2 Smaller Hospitals?	Respondents, No. (%) [95% CI]b
	More Often at the Small Hospital With No Relationships	Same at Both Hospitals	More Often at the Small Hospital Affiliated With a Top Cancer Hospital
Patients get all the tests and treatment that experts think are the best for patients.	44 (5.2) [3.7-6.8]	470 (46.5) [43.2-49.7]	484 (47.2) [43.9-50.4]
Surgeons use small incisions and a camera for surgery. (minimally invasive)	45 (4.9) [3.4-6.4]	587 (49.7) [46.5-52.9]	368 (44.2) [41.0-47.4]
Patients have a major complication after surgery. (safety outcome)	318 (31.4) [28.4-34.3]	625 (61.0) [57.8-64.2]	56 (6.5) [4.8-8.3]
Patients need to stay longer than normal in the hospital after surgery. (safety outcome)	266 (26.4) [23.6-29.3]	666 (64.7) [61.6-27.8]	67 (7.7) [5.8-9.5]
Patients have to be admitted again in the hospital for a complication after surgery. (safety outcome)	318 (31.0) [28.0-34.0]	623 (61.4) [58.3-64.6]	54 (6.1) [4.5-7.8]
Patients die because of complications from surgery. (safety outcome)	307 (30.2) [27.3-33.2]	639 (62.6) [59.5-65.7]	53 (6.1) [4.4-7.8]
Inferior safety indicated for at least 1 of the 4 safety outcomes.c	474 (46.8) [63.6-50.1]	NA	134 (15.1) [12.6-17.5]
Surgery cures cancer.	45 (4.7) [3.3-6.1]	587 (57.8) [54.6-61.0]	368 (36.5) [33.4-39.6]
Which hospital would you choose for a complex surgery for cancer?	221 (22.6) [19.9-25.3]	NA	785 (76.9) [74.1-79.6]

^aSurvey questions were developed using focus groups and pilot surveys prior to the final study distribution. To achieve a nationally representative sample, the survey was repeatedly distributed using a probability-based sampling method to mirror the US population until a minimum of 1000 surveys were completed. A total of 1738 were distributed for a response rate of 58.1%. Sixteen surveys were excluded because they were incomplete.

^bTo account for variable response rates across sociodemographic strata, survey responses were weighted (age, sex, race/Hispanic ethnicity, education, region, household income, home ownership status, and residence in a metropolitan area) to maintain the sociodemographic profile of the US population. For each question, the proportion of respondents choosing not to answer was less than 2% (nonresponses not shown, therefore row total may not equal 100%).

^cPercent of respondents who indicated that either hospital had inferior safety outcomes with respect to at least 1 of the 4 safety outcome questions listed directly above this row in the table.

Discussion

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.