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Advocate Aurora Health, located in the north‐central United States, is the result of a merger between two large health care organizations in April 2018. The health care system comprises 26 hospitals, offers more than 500 sites of care, and employs 75,000 team members. This article discusses the effects that coronavirus disease 2019 had on the perioperative services departments while directors and site leaders were still managing the complexities of the merger. Included are strategies used to address the challenges created by the pandemic, special considerations based on level‐of‐care capacity, the effect that the hold on elective surgeries had on staffing assignments, the reactivation process when elective surgery resumed, and the importance of keeping the perioperative team members informed and safe. It also illustrates how facing the challenges caused by the pandemic helped to solidify the merger of the two health care organizations.

I use a 2010 non-profit hospital merger in Ohio to study the effect of market concentration on market outcomes. Using the Synthetic Control Method and Truven MarketScan data, I document three findings. First, courts are lenient to non-profit mergers, and I cast doubt on this practice by showing that the studied merger led to a 123% increase in the payments for inpatient childbirth services. Second, I provide the first empirical evidence for the conjecture that mergers increase out-of-pocket payments and reduce the utilization of care. Last, I show that the effect of market power on market outcomes is asymmetric: the increase in payments and welfare loss created by a merger persist after the merger is rescinded. Thus, even successful FTC challenges may not revert the effect of harmful mergers, and it is essential to deny such mergers before they proceed.

To succeed in the assisted reproductive technology industry, physician owners of fertility practices have to develop a wide array of business skills and expertise. In today's business world, a natural next step for many assisted reproductive practices is exploring potential mergers, sales, or acquisitions. This article will explore what factors physician owners of fertility practices should consider before pursuing a potential sale or merger; how to prepare for such a transaction; and what to expect once a transaction is underway.

Objective We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration. Data sources Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019. Study design Exploratory study using thematic comparative analysis to describe factors that may lead to high performance. Data collection We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs. Principal findings Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise." Conclusions Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

PurposeDespite the continuation of hospital mergers in many western countries, it is uncertain if and how hospital mergers impact the quality of care. This poses challenges for the regulation of mergers. The purpose of this paper is to understand: how regulators and hospitals frame the impact of merging on the quality and safety of care and how hospital mergers might be regulated, given their uncertain impact on quality and safety of care.Design/methodology/approachThis paper studies the regulation of hospital mergers in The Netherlands. In a qualitative study design, it draws on 30 semi-structured interviews with inspectors from the Dutch Health and Youth Care Inspectorate (Inspectorate) and respondents from three hospitals that merged between 2013 and 2015. This paper draws from literature on process-based regulation to understand how regulators can monitor hospital mergers.FindingsThis paper finds that inspectors and hospital respondents frame the process of merging as potentially disruptive to daily care practices. While inspectors emphasise the dangers of merging, hospital respondents report how merging stimulated them to reflect on their care practices and how it afforded learning between hospitals. Although the Inspectorate considers mergers a risk to quality of care, their regulatory practices are hesitant.Originality/valueThis qualitative study sheds light on how merging might affect key hospital processes and daily care practices. It offers opportunities for the regulation of hospital mergers that acknowledges rather than aims to dispel the uncertain and potentially ambiguous impact of mergers on quality and safety of care.

Background Birmingham Women's and Children's NHS Foundation Trust was formed in February 2017 following an acquisition. The Library and Knowledge Services (LKS) merged while operating across two hospital sites. A priority for the merged Library and Knowledge Service was to integrate e-collections. A literature review identified six papers reporting health libraries that had merged and integrated e-collections. Objectives A priority for the merged Library and Knowledge Service was to integrate e-collections. Methods To ensure equitable and cost-effective access to an extended collection, an audit of pre-existing e-collections was conducted. Electronic licence agreements enabling cross-site access were negotiated. A new OpenAthens ID was created. Results The integration of e-collections enabled Trust staff access to a greater number of e-journals and additional e-content, and an overall cost-saving was achieved. Discussion This case study supports existing literature stating that integrating collections increases the number of e-journals. It further identifies cost-difference in acquiring cross-site access to e-journals compared to databases providing full-text e-journals and additional e-content. Conclusion Integrating e-collections enables equity of access and value. A national co-ordinated approach to procurement of e-collections will further support equity and best value throughout NHS LKS.

EXECUTIVE SUMMARY Health system mergers and acquisitions have increased exponentially in recent years as an apparent result of the Affordable Care Act. Mergers and acquisitions are seen as a way to control interdependencies within the market, control costs, leverage debt, and negotiate better rates among health insurers. Regardless of the impetus for a merger, the largest predictor of its success or failure lies within the organizational culture. The purpose of this research was to assess the current organizational culture and preferred organizational culture of two competing health organizations prior to a planned merger, and then to determine whether there were significant differences between the premerger cultures and the postmerger preferred organizational culture using the Competing Values Framework (CVF). Current culture is defined as the premerger culture as measured by the CVF, and preferred culture is defined as the self-identified preferred traits and characteristics of the postmerger culture as measured by the CVF. The study findings indicated a statistically significant difference between the premerger cultures of the health systems. However, respondents from both health systems preferred a postmerger organizational culture that was statistically the same. A review of the results along with best practices for health system leaders follows.

Background Despite mergers have increasingly affected hospitals in the recent decades, literature on the impact of hospitals mergers on healthcare quality measures (HQM) is still lacking. Our research aimed to systematically review evidence regarding the impact of hospital mergers on HQM focusing especially on process indicators and clinical outcomes. Methods The search was carried out until January 2020 using the Population, Intervention, Comparison and Outcome model, querying electronic databases (MEDLINE, Scopus, Web Of Science) and refining the search with hand search. Studies that assessed HQM of hospitals that have undergone a merger were included. HQMs were analyzed through a narrative synthesis and a strength of the evidence analysis based on the quality of the studies and the consistency of the findings. Results The 16 articles, included in the narrative synthesis, reported inconsistent findings and few statistically significant results. All indicators analyzed showed an insufficient strength of evidence to achieve conclusive results. However, a tendency in the decrease of the number of beds, hospital staff and inpatient admissions and an increase in both mortality and readmission rate for acute myocardial infarction and stroke emerged in our analysis. Conclusions In our study, there is no strong evidence of improvement or worsening of HQM in hospital mergers. Since a limited amount of studies currently exists, additional studies are needed. In the meanwhile, hospital managers involved in mergers should adopt a clear evaluation framework with indicators that help to periodically and systematically assess HQM ascertaining that mergers ensure and primarily do not reduce the quality of care.

Purpose Hospital mergers are common in the United Kingdom and internationally. However, mergers rarely achieve their intended benefits and are often damaging. This study builds on existing literature by presenting a case study evaluating a merger of two hospitals in Oxford, United Kingdom with three distinct characteristics: merger between two university hospitals, merger between a generalist and specialist hospital and merger between two hospitals of differing size. In doing so, the study draws practical lessons for other healthcare organisations.Design/methodology/approach Mixed-methods single-case evaluation. Qualitative data from 19 individual interviews and three focus groups were analysed thematically, using constant comparison to synthesise and interpret findings. Qualitative data were triangulated with quantitative clinical and financial data. To maximise research value, the study was co-created with practitioners.Findings The merger was a relative success with mixed improvement in clinical performance and strong improvement in financial and organisational performance. The merged organisation received an improved inspection rating, became debt-free and achieved Foundation Trust status. The study draws six lessons relating to the contingencies that can make mergers a success: (1) Develop a strong clinical rationale, (2) Communicate the change strategy widely and early, (3) Increase engagement and collaboration at all levels, (4) Be transparent and realistic about the costs and benefits, (5) Be sensitive to the feelings of the other organisation and (6) Integrate different organizational cultures effectively.Originality/value This case study provides empirical evidence on the outcome of merger in a university hospital setting. Despite the relatively positive outcome, there is no strong evidence that the benefits could not have been achieved without merger. Given that mergers remain prevalent worldwide, the practical lessons might be useful for other healthcare organisations considering merger.

Key Points Question Is a full-integration approach to a hospital merger associated with improved quality in an acquired hospital? Findings This quality improvement study of 181 252 patients found that a full-integration approach to a hospital merger was associated with an absolute reduction in crude and adjusted mortality rates by the end of the 3-year intervention period. Meaning These results suggest that a full clinical and operational integration approach to a hospital merger may improve outcomes as measured by quality and safety metrics, including mortality rates., This quality improvement study assesses a full-integration approach to hospital mergers using quality metrics that track hospital mortality and readmission., Importance Hospital consolidations have been shown not to improve quality on average. Objective To assess a full-integration approach to hospital mergers based on quality metrics in a safety net hospital acquired by an urban academic health system. Design, Setting, and Participants This quality improvement study analyzed outcomes for all nonpsychiatric, nonrehabilitation, non-newborn patients discharged between September 1, 2010, and August 31, 2019, at a US safety net hospital that was acquired by an urban academic health system in January 2016. Interrupted time series and statistical process control analyses were used to assess the main outcomes and measures. Data sources included the hospital’s electronic health record, Centers for Medicare & Medicaid Services Hospital Compare, and nursing quality reports. Exposures A full-integration approach to the merger that included: (1) early administrative and clinical leadership integration with the academic health system; (2) rapid transition to the academic health system electronic health record; (3) local ownership of quality metrics; (4) system-level goals with real-time actionable analytics through combined dashboards; and (5) implementation of value-based and other analytic-driven interventions. Main Outcomes and Measures The primary outcome was in-hospital mortality. Secondary outcomes included 30-day readmission, patient experience, and hospital-acquired conditions. Results The 122 348 patients in the premerger (September 2010 through August 2016) and the 58 904 patients in the postmerger (September 2016 through August 2019) periods had a mean (SD) age of 55.5 (22.0) years; the total sample of 181 252 patients included 112 191 women (61.9%), the payor mix was majority governmental (144 375 patients [79.7%]), and most admissions were emergent (121 469 patients [67.0%]). There was a 0.71% (95% CI, 0.57%-0.86%) absolute (27% relative) reduction in the crude mortality rate and 0.95% (95% CI, 0.83%-1.12%) absolute (33% relative) in the adjusted rate by the end of the 3-year intervention period. There was no significant improvement in readmission rates after accounting for baseline trends. There were fewer central line infections per 1000 catheter days, fewer catheter-associated urinary tract infections per 1000 discharges, and a higher likelihood of patients recommending the hospital or ranking it 9 or 10. Conclusions and Relevance In this quality improvement study, a hospital merger with a full-integration approach to consolidation was found to be associated with improvement in quality outcomes.

Background: Despite a lack of supporting evidence, hospitals continue to merge in pursuit of quality improvements. Purpose: We seek to develop a more thorough understanding of the quality effects of hospital mergers by integrating various theoretical perspectives using a mixed-methods design. Methodology: Quantitatively, we tested the quality effect of all consummated hospital mergers in the Netherlands between 2008 and 2014 on 15 quality indicators (with 82 measurements at hospital, department, and disease levels) using a difference-in-difference approach with Bonferroni correction. Qualitatively, we conducted three comparative case studies to examine how hospital executives, managers, and medical professionals perceive the quality impact of hospital mergers. Results: Our quantitative results reveal few significant effects of hospital mergers on quality of care at all levels. After applying Bonferroni correction, two quality indicators are negatively associated with hospital mergers. However, the qualitative results indicate that hospital staff have positive perceptions of the mergers’ quality implications, resulting from scale and shock effects. Conclusion: The perceptions of hospital staff regarding mergers diametrically oppose their measurable effects. However, the operationalization of quality by hospital staff members differs considerably from the way it is quantitatively measured. The positive perceptions of hospital staff toward mergers could further contribute to the institutionalization of mergers as a quality improvement strategy. Practice Implications: Hospital managers seeking measurable quality improvements should be wary of merging, despite potential positive perceptions toward it within the organization. In case they do decide to merge, mitigating difficulties in the postmerger integration processes seem most pertinent to achieve measurable effects

Purpose Mergers are important and challenging elements in hospital reforms. The authors study the social aspects of management and the roles of middle managers in the aftermath of a hospital merger. Especially, the purpose of this paper is to investigate how professional staff and middle managers perceive their relationships with top managers several years after the merger. Design/methodology/approach A survey was conducted among the professional staff in two merging hospitals’ units six years after a merger. Based on the main findings from this survey, a follow-up interview study was done with a group of middle managers. Findings The management practices were diagnostic with few interactive or communicative activities. The respondents expressed that mistrust developed between the staff and the top management, and a lack of involvement and interaction lead to decoupled and parallel organizations. Social controls, based on shared norms, had not been developed to create mutual commitment and engagement. Practical implications Policy makers should be aware of the need in profound change processes not only to change the tangible elements, but to take care of changing the less tangible elements such as norms and values. Professionals in hospitals are in powerful positions, and changes in such organizations are dependent on trust-building, bottom-up initiatives and evolutionary pathways. Originality/value The paper addresses the need to understand the dynamics of the social aspect in managing hospitals as knowledge-intensive organizations when comprehensive restructuring processes are taking place over several years.

States can challenge proposed hospital mergers by using antitrust laws to prevent anticompetitive harms. This observational study examined additional state laws-principally charitable trust, nonprofit corporation, health and safety, and certificate-of-need laws-that can serve as complements and substitutes for antitrust laws by empowering states to be notified of, review, and challenge proposed hospital mergers through administrative processes. During the period 2010-19, 862 hospital mergers were proposed, but only forty-two (4.9 percent) were challenged by states, including thirty-five by states without federal involvement, of which twenty-five (71.4 percent) originated in the eight states with the most robust merger review authority. The twenty-five challenges resulted in two mergers being blocked; three being abandoned; and twenty being approved with conditions, including seven with competitive-impact conditions. Hospital market concentration and prices increased at similar rates in these eight states versus other states, potentially because most challenges allowed mergers to proceed with conditions that did not adequately address competitive concerns. Although these findings do not reveal an optimal state framework, elements of advanced state merger review authority may have the potential to improve poorly functioning hospital markets.

OBJECTIVES Hospital mergers and acquisitions are increasingly used as a strategy to facilitate value-based care. However, no studies have assessed health care utilization (HCU) and patient flow across merged institutions. We aim to evaluate patient population distribution, HCU, and patient flow across a recent hospital merger of an academic medical center (AMC), a primary and specialty care alliance (PSC), and a community-based medical center (CMC). STUDY DESIGN This was a retrospective observational study. METHODS The study used 2018 adult demographic and encounter data from electronic health records. Patients' parent health care institution was determined by the most frequently visited site of face-to-face visits. Differences in patient demographics and HCU (ie, emergency department [ED] visits, hospitalizations, primary care visits) were compared. Independent factors associated with utilization were identified using adjusted logistic regression models. RESULTS A total of 406,303 adult patients were identified in the cohort. The PSC setting, compared with the AMC and the CMC, had significantly more female (62.7% vs 54.4% and 58.5%, respectively), older (mean [SD] age, 52.0 [18.1] vs 51.1 [17.8] and 49.2 [17.8] years), and privately insured (63.6% vs 51.3% and 56.0%) patients. A higher proportion of patients at the CMC (27.5%) visited the ED compared with patients at the AMC (10.8%). Approximately 1645 primary care patients (7%) at the CMC setting went to the AMC for specialized care such as oncology, surgery, and neurology. CONCLUSIONS Hospital mergers are increasing across the United States, allowing AMCs to expand their reach. These findings suggest that patients mainly sought care at their parent health care institution, yet appropriately received specialized care at the AMC. These results provide insights for future mergers and guide resource allocation and opportunities for improving care delivery.

Despite rural hospitals' central role in their communities, they are increasingly in financial distress and may merge with other hospitals or health systems, potentially reducing service lines that are less profitable or duplicative of services that the acquirer also offers. Using hospital discharge data from thirty-two Healthcare Cost and Utilization Project State Inpatient Databases from the period 2007-18, we examined the influence of rural hospital mergers on changes to inpatient service lines at hospitals and within their catchment areas. We found that merged hospitals were more likely than independent hospitals to eliminate maternal/neonatal and surgical care. Whereas the number of mental/substance use disorder-related stays decreased or remained stable at merged hospitals and within their catchment areas, it increased for unaffiliated hospitals and their catchment areas, indicating a potential unmet need in the communities of rural hospitals postmerger. Although a merger could salvage a hospital's sustainability, it also could reduce service lines and responsiveness to community needs.

Key Points Question Are mergers and acquisitions associated with the quality of care at rural hospitals? Findings This case-control study including 172 merged hospitals and 266 comparison hospitals that remained independent compared premerger to postmerger changes in in-hospital mortality for common conditions and complications for elective procedures. Adjusted for patient, hospital, and community characteristics, decreases in mortality among stays for acute myocardial infarction, heart failure, stroke, and pneumonia postmerger were greater at merged hospitals than at comparison hospitals. Meaning These findings suggest that rural hospital mergers were associated with better mortality outcomes for certain conditions., This case-control study examines changes in quality of care at rural hospitals that merged with or were acquired by other hospitals compared with hospitals that remained independent., Importance Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation. Objectives To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent. Design, Setting, and Participants In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy–eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020. Exposures Hospital mergers. Main Outcomes and Measures The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries. Results A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, −2.825 to −0.685) percentage points greater at merged hospitals than at comparison hospitals (P

In response to the merger of our 248-bed community hospital with a new health system, a multidisciplinary team began a journey of holistic transformation via the evolution of a new rounding process called Leadership, Ownership, Transformation, Unity, and Sustainability (LOTUS) in the 20-bed ICU. Morphing from a hierarchical practice structure with limited engagement of multidisciplinary members, the LOTUS initiative (named for the blossom whose petals surround its core, the patient) afforded each discipline (petal) an equal voice and allowed a once-fragmented team to work cohesively, collaboratively, and at the highest level of the scope of practice for each discipline, thus affording expert guidance during care planning while providing a method to collect quality metrics. LOTUS allows us to view our patients in a new way as we refocused goal determination on patients and their families. The restructuring and evolution into a high-functioning team was targeted with the goal of enhancing quality critical care for patients, which, in the literature, has correlated with improved patient safety and decreased mortality and ICU length of stay.

Merger processes between hospitals have high benefit potential for patients, staff and managers. This integration of health centres can improve the quality and safety in patient care. Additionally, cooperative processes enhance the sustainability of the health system, by increasing team spirit, giving innovative ideas and improving staff satisfaction. In this article, the critical factors for successful hospital mergers and acquisitions in the Public Health System were considered to develop a brief guide to help with the organisation of a merger process. Five sections were designed: Strategic administration and objectives, Staff management, New hospital complex structure, Processes and Results. This guide facilitates the communication between a variety of stakeholders, thus improving the engagement between all members of the new healthcare system. This could be particularly important for countries with large regional variance in the organisation of health care and resources.

After hospital mergers, unit work environments are at risk of being unhealthy due to poor intradisciplinary two-way communication in times of change. This quality improvement project explored the impact a 4-week, social-media-based, intradisciplinary communication strategy had on a postmerger intensive care unit work environment. The sample (N = 14) included 11 bedside nurses and three administrative nurses working in a 22-bed southwestern US ICU. The participants took part in a Facebook closed-group community of practice called Nurse to Nurse, with a total of 25.9% participation rate. Eleven participants completed the pre-Nurse to Nurse survey, a 20.4% completion rate, while eight participants completed the post-Nurse to Nurse survey, a 14.8% completion rate. After the conclusion of Nurse to Nurse, the overall mean skilled communication survey score increased to 3.79, a 1.6% improvement. Question 14, which measured zero-tolerance behavior perception, exhibited a mean of 2.3% improvement, boosting this metric to excellent status. Utilization data revealed 68 comments posted within Nurse to Nurse implementation, with 56 showing horizontal communication (73.5%) and 24 displaying vertical communication (26.5%). A total of 217 bedside nurse views (81.3%) and 50 administrative nurse views (18.7%) were noted. Nurse to Nurse, an online communication-focused community of practice, enhanced communication among bedside and administrative nurses working in a postmerger intensive care unit setting.

While most studies of health care industry consolidation focus on impacts on prices or quality, these are not its only potential impacts. This exploratory qualitative study describes industry and community stakeholder perceptions of the impacts of cumulative hospital, practice, and insurance mergers, acquisitions, and affiliations in Pittsburgh, Pennsylvania. Since the 1980s, Pittsburgh’s health care landscape has been transformed and is now dominated by competition between 2 integrated payer-provider networks, health care system UPMC (and its insurance arm UPMC Health Plan) and insurer Highmark (and its health care system Allegheny Health Network). Semi-structured interviews with 20 boundary-spanning stakeholders revealed a mix of perceived impacts of consolidation: some positive, some neutral or ambiguous, and some negative. Stakeholders perceived consolidation’s positive impacts on long-term viability of health care facilities and their ability to adopt new care models, enhanced competition in health insurance, creation of foundations, and pioneering medical research and innovation. Stakeholders also believed that consolidation changed geographic access to care, physician referral behaviors, how educated patients were about their health care, the health care advertising environment, and economies of surrounding neighborhoods. Interviewees noted that consolidation raised questions about what the responsibilities of non-profit organizations are to their communities. However, stakeholders also reported their perceptions of negative outcomes, including ways in which consolidation had potentially reduced patient access to care, accountability and transparency, systems’ willingness to collaborate, and physician autonomy. As trends toward consolidation are not slowing, there will be many opportunities to experiment with policy levers to mitigate its potentially negative consequences.

Provider organizations are increasing in complexity, as hospitals acquire physician practices and physician organizations grow in size. At the same time, hospitals are merging with each other to improve bargaining power with insurers. We analyze 29 quality measures reported to the Center for Medicare and Medicaid Services’ Hospital Compare database for 2008 to 2015 to test whether vertical integration between hospitals and physicians or increases in hospital market concentration influence patient outcomes. Vertical integration has a limited effect on a small subset of quality measures. Yet increased market concentration is strongly associated with reduced quality across all 10 patient satisfaction measures at the 95% confidence level (p < .05) and 6 of the 10 patient satisfaction measures remain statistically significant with a Bonferroni corrected p value (p < .005). Regulators should continue to focus scrutiny on proposed hospital mergers, take steps to maintain competition, and reduce counterproductive barriers to entry.

The number of rural hospital mergers has increased substantially in recent years. A commonly reported reason for merging is to increase access to capital. However, no empirical evidence exists to show whether capital expenditures increased at rural hospitals after a merger. We used a difference-in-differences approach to determine whether total capital expenditures changed at rural hospitals after a merger. The comparison group (rural hospitals that did not merge during the 2012 through 2015 study period) was weighted using inverse probability of treatment weights. The key outcome measure was logged total capital expenditures.Merging resulted in a 26% increase in capital expenditures and also was associated with a significant improvement in plant age. The postmerger improvement in plant age may have been partially attributable to merger-related accounting changes and partially attributable to increased capital expenses, possibly on long-term asset renovations and replacement.These findings suggest that through mergers, rural hospital board members and executives who have accepted or are considering a merger may improve a hospital's ability to increase capital expenditures. Further, increased capital investments in rural hospitals may be an important signal to the community that the acquirer intends to keep the rural hospital open and continue providing some volume and level of services within the community. Future research should determine how capital is spent after a merger.

The United States is experiencing another wave of hospital mergers. Whether patients benefit from these mergers, however, remains an open issue for many interested stakeholders. One measure of the potential benefit of hospital mergers is how they affect patient experience. This study used a quasi-experimental design to examine the relationship between hospital mergers and four different Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings (i.e., overall, physician communication, nurse communication, and staff responsiveness). The study findings showed an association between hospitals that experienced a merger and slower growth in HCAHPS scores for two of the four HCAHPS domains (overall and nurse communication) when compared to matching hospitals that did not merge. Findings from this study can guide and inform hospital administrators, health system boards, state and federal government regulators and policymakers, and others across the spectrum of healthcare stakeholders.

To capture the value of the Scarborough Health Network amalgamation, a value realization framework (VRF) was developed, based on three themes and nine goals. Each goal was mapped to key strategies and indicators that signalled our delivery of value to the community. Value was achieved when indicators moved in the desired direction. The VRF acknowledged that integration is a journey and identified value in the short, medium and long term. Four quarterly VRF progress reports were completed, illustrating a positive story of the post-merger period. The VRF provided a standardized framework for tracking and monitoring strategies for a successful organizational transition.