• Omar I Ramadan, Paul R Rosenbaum, Joseph G Reiter, Siddharth Jain, Alexander S Hill, Sean Hashemi, Rachel R Kelz, Lee A Fleisher, and Jeffrey H Silber.
• Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
• Ann. Surg. 2024 Apr 1; 279 (4): 631639631-639.

ObjectiveTo compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.Summary Background DataIt is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients.MethodsUsing Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.ResultsWe formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001].ConclusionsPatients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

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