Exhibit 3: Change over time in performance measures of affiliating and nonaffiliating rural hospitals.

Performance measure	Baseline mean		Incremental change for affiliating hospitals, by number of years after affiliation
	Affiliating hospitals	Weighted nonaffiliating hospitals	1	2	3	4	5	6
Structure
Technology composite	4.22	4.09	−0.30***	−0.32**	−0.32**	−0.22	−0.28	−0.42
Obstetric care services (%)	51.0	49.2	−6.5**	−6.5*	−8.0**	−10.0**	−12.9**	−13.6**
Rural health clinic (%)	26.1	26.6	−2.5	2.1	2.3	1.6	0.8	3.6
Primary care department (%)	36.9	33.1	−7.4**	−9.6**	−10.9**	−9.6*	−16.8***	−19.2***
Utilization
Admissions	2,208	2,076	−195*	−76	−195	−150	−202	−408
Emergency department visits	13,720	12,424	−197	−2	−186	316	−274	−524
Outpatient visits (nonemergency)	60,020	56,829	−10,280***	−14,133***	−17,455***	−16,955***	−20,555***	−21,200***
Financial
Operating margin (%)	−1.6	−1.8	0.44	1.61**	2.17***	3.38****	3.56***	2.75*
Asset-to-liability ratio	2.2	2.4	0.0	−0.1	−0.2	−0.2	−0.1	−0.1
Uncompensated or unreimbursed care as percentage of operating costs (%)	7.5	7.3	1.05****	0.94**	1.06**	1.36***	1.92***	1.95***
Quality
Patient experience composite	−0.10	−0.09	−0.078	−0.121	−0.172*	−0.156	−0.083	−0.022
30-day hospitalwide all-cause unplanned readmissions (%)	15.5	15.4	1.9	2.4	4.6	13.2**	1.8	−4.1

SOURCE Authors’ analysis of data from the American Hospital Association Annual Survey (2008–17), Healthcare Cost Report Information System (2008–17), and Hospital Compare (2011–17). NOTES The technology composite measure and the patient experience composite measure are explained in the notes to exhibit 1. Significance refers to p-values less than 0.05.

^*p < 0.01

^**p < 0.05

^***p < 0.01

^****p < 0.001