• Siddharth Jain, Paul R Rosenbaum, Joseph G Reiter, Omar I Ramadan, Alexander S Hill, Sean Hashemi, Rebecca T Brown, Rachel R Kelz, Lee A Fleisher, and Jeffrey H Silber.
• Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA. sid.jain@yale.edu.
• J Gen Intern Med. 2024 May 1; 39 (6): 902911902-911.

BackgroundWe define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.ObjectiveTo compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.DesignA matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.Main Measures30-day (primary) and 90-day (secondary) all-cause mortality.Key Results30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality.LimitationsThe study used claims-based data.ConclusionsIn aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.

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