Abstract
Background
Cancer centers provide superior care but are less accessible to rural populations. Health systems that integrate a cancer center may provide broader access to quality surgical care, but penetration to rural hospitals is unknown.
Methods
Cancer center data were linked to health system data to describe health systems based on whether they included at least one accredited cancer center. Health systems with and without cancer centers were compared based on rural hospital presence. Bivariate tests and multivariable logistic regression were used with results reported as P-values and odds ratios (OR) with 95% confidence intervals (CIs).
Results
Ninety percent of cancer centers are in a health system, and 72% of health systems (434/607) have a cancer center. Larger health systems (P = .03) with more trainees (P = .03) more often have cancer centers but are no more likely to include rural hospitals (11% vs 6%, P = .43; adjusted OR .69, 95% CI .28-1.70). The minority of cancer centers not in health systems (N = 95) more often serve low complexity patient populations (P = .02) in non-metropolitan areas (P = .03).
Discussion
Health systems with rural hospitals are no more likely to have a cancer center. Ongoing health system integration will not necessarily expand rural patients’ access to surgical care under existing health policy infrastructure and incentives.
Key Takeaway
• Most health systems include an accredited cancer center; however, there are notable differences between health systems that do and do not have a cancer center with respect to size, academic affiliation, and rural reach. • Health systems with rural hospitals were no more likely to have cancer centers, so current trends in health system formation are unlikely to expand rural patients’ access to specialty cancer care such as surgery. • Integration of rural hospitals into health systems that offer high-quality subspecialty surgical care such as accredited cancer centers may be an effective strategy to increase access for rural patients.
Introduction
Cancer centers such as comprehensive cancer centers provide superior surgical care but are less accessible in rural areas. Other barriers such as race/ethnicity, lack of insurance coverage, far travel distance, and low socioeconomic class can make it especially difficult for rural residents to seek and receive high-quality cancer treatment. 1 More United States (US) hospitals, including rural hospitals, are merged or acquired by larger entities, resulting in a rise in health system formation.2,3 Likewise, other less formal brand-sharing arrangements are becoming more frequent. 4 When health systems with cancer centers integrate with rural hospitals, access to quality surgical care may be improved through streamlined referrals, improved care coordination, and potentially health system-level programs and quality infrastructure.
The extent of cancer center participation in health systems or their geographic and demographic reach is unknown. A better understanding of the current landscape is needed to design future studies to assess the quality of cancer care at the health system level and to determine optimal strategies for delivering accessible, high-quality surgical care to marginalized groups such as rural residents in the setting of increasing health system consolidation.
We evaluated health system participation among cancer centers that are accredited by the Commission on Cancer (CoC), an American College of Surgeons (ACS) program. Approximately two-thirds of cancer centers are CoC-accredited, meaning that they achieve minimum standards for case volume, services, and quality. 5 We anticipated that most CoC-accredited centers participate in a health system, and this participation may impact access to quality surgical care. We hypothesized that health systems with CoC-accredited centers are more likely to include rural hospitals.
Methods
Objective
We created a linked dataset of CoC-accredited centers and health system hospitals using the ACS and the Agency for Healthcare Research and Quality (AHRQ). Institutional Review Board approval was not necessary to access data. Our general objectives were to describe the proportion of CoC-accredited centers that are affiliated with a health system and to compare the contextual factors associated with health systems integrating a CoC-accredited center. We sought to evaluate the likelihood that health systems with CoC-accredited centers included rural hospitals as a potential strategy for making specialized cancer care such as surgery accessible to rural residents.
Study Design
From June 1, 2021 through August 1, 2021, we queried the CoC database of cancer centers. Each CoC-accredited center was matched to a hospital in the Compendium of US Health Systems, a comprehensive taxonomy of health system participation for all US hospitals that was developed by the AHRQ. 6
Definition of Health System
Health systems were categorized by AHRQ based on a definition of vertically integrated health systems, which requires at least one hospital and at least one physician group that offer both primary and specialty care and are connected via common ownership or joint management. Though the definition requires a minimum of one acute care hospital, most health systems have more than one. 6
Study Population
Commission on Cancer Programs and Frequency of Health System Participation. 5
NCI = National Cancer Institute; CEO = Chief Executive Officer.
Matching Cancer Centers to Health Systems
Our process for matching cancer centers and health systems entailed text searches by hospital name, city/state, and street address. Exact matches by hospital name or address were considered the same facility. For inexact matches (ie, same city/state but different name and/or address), we used web-based searches to determine any recent changes in name or ownership. We then used Google Maps to map hospital locations and considered facilities as matched between the 2 data sources if they were on the same campus.
Data Collection
Population Characteristics of Cancer Centers in vs Not in Health Systems.
PCTPOVALL_2019 = Estimated percent of all people of all ages in poverty in 2019.
Health System Characteristics
Health system characteristics, which were obtained from the AHRQ Compendium, included size (number of hospitals, beds, and annual discharges), number of primary and specialty providers, teaching status including number of residents in training, whether the health system encompassed single or multiple states, health system ownership (investor owned vs non-investor owned), and measures of uncompensated and disproportionate share care burden. Health systems were characterized as having a high uncompensated care burden if they were in the top quintile of uncompensated care among US health systems based on a ratio of total uncompensated care (charity care and bad-debt expense) to total operating expense. Health systems were further characterized by whether they have at least one hospital with a high disproportionate share (DSH) patient percentage based on the Centers for Medicare and Medicaid services, which considers the percent of patients with Medicare Supplemental Security Income and Medicaid insurance. 7 Health systems were categorized based on whether they included at least one rural hospital.
Statistical Analysis
We used descriptive statistics to characterize the proportion of health systems with a cancer center. Chi-squared and Wilcoxon rank-sum tests were used to compare the characteristics of health systems with cancer centers vs those without one, including whether there was at least one rural hospital in the health system. In an adjusted analysis, we performed multivariable logistic regression to examine whether integration of a rural hospital was associated with health systems having a cancer center. Covariates were selected a priori and included number of hospitals, multistate system, number of beds, ratio of specialist to primary care providers, whether hospitals are majority investor-owned, number of residents in training, and uncompensated care burden. Results are reported as odds ratios (95% confidence intervals). Statistical analyses were performed using Stata version 15 (StataCorp LLC).
Results
Cancer Center Participation
Among 1079 cancer centers, 92% (n = 995) were matched to the AHRQ Compendium of US hospitals. An additional 104 CoC-defined integrated network cancer programs and 9 NCI-designated networks mapped to an individual hospital in the AHRQ Compendium were also included as cancer centers for the purpose of the analysis (other integrated network cancer programs and NCI-designated networks mapped to AHRQ health systems and were not included in the hospital-level analysis). In total, there were 1108 cancer center hospitals amongst 6494 US hospitals in the AHRQ Compendium (17%).
Health System Participation
Most cancer centers (91%) are in a health system, including 90% of NCI-designated Comprehensive cancer centers, 94% of Academic cancer centers, 93% of Comprehensive Community cancer centers, 87% of Community cancer programs, 62% of Hospital Associate cancer programs, 96% of CoC-defined Integrated Networks, and 78% of NCI-designated Networks (Table 1).
While most cancer centers are in metropolitan areas, ones that are not integrated in a health system are more often located in non-metropolitan areas (30.5% vs 10.5%, P=<.001). Cancer centers that do not participate in health systems most frequently serve populations that earn lower median household incomes (US$60,249 vs US$64,648; P = .002) and have higher unemployment rates (3.7% vs 3.5%; P = .022). Cancer centers not in health systems have lower rates of residents with a bachelor’s degree or higher (27.2% vs 32.5%, P=<.001) and less racial and ethnic diversity (6% vs 10% Black; P=<.001) (1% vs 2% Asian; P=<.001) (3% vs 5% Pacific Islander; P = .003) (6% vs 9% Hispanic; P = .002) (Table 2).
Non-system cancer centers also serve a higher proportion of Medicare patients (41.4% vs 32.3%, P=<.001) and have higher worse financial performance (operating margin −1.06 vs 2.06, P = .012).
Health Systems with at Least One Cancer Center
Seventy-two percent (N = 434) of health systems have at least one cancer center.
Characteristics of Health Systems With and Without a Cancer Center.
Factors associated with a health system having at least one accredited cancer center. OR=odds ratio; UCL=upper confidence limit of 95% confidence interval; LCL=lower confidence limit of 95% confidence interval.
The multivariable regression model (Figure 1) demonstrated no association between a health system having a cancer center and integrating a rural hospital (OR .69, 95% CI .28-1.70). An increase in health system size (represented by the number of hospitals per system) is associated with an increased likelihood of having a cancer center (OR for each one hospital increase: 1.18, 95% confidence interval 1.02-1.38; P = .028). There is also a positive association between a health system having a cancer center and the number of residents in the health system (OR for each single resident increase: 1.00, 95% confidence interval 1.00-1.00; P = .032).
Discussion
In this study, we characterized cancer center participation in health systems and identified the characteristics of health systems with and without cancer centers. We found that health systems with cancer centers are larger and more likely to have academic affiliations but are no more likely to include a rural hospital. Though health system integration is often touted as a strategy to increase access for rural populations, our data suggest that the rise in hospital consolidation currently does little to expand access to patients treated at rural hospitals and may not be an effective strategy to deliver specialized surgical care to rural residents.
The upward trend in the consolidation of the health care industry has been observed over several decades but appears to be accelerating in recent years, especially for struggling rural hospitals.2,3 During this time there has also been an increase in network affiliations that do not involve a formal merger or acquisition, but in which affiliate hospitals pay a fee to a larger network to gain access to network resources and share branding. 4 While the effect of these integrations on patient outcomes is mixed, there is some evidence that patients treated within integrated health systems are more likely to receive guideline-concordant cancer care and may have better oncologic outcomes.8,9
The finding that most cancer centers are in health systems is not surprising given the common characteristics of hospitals in health systems and the standards required for CoC-accreditation. Compared to hospitals not in health systems, hospitals in health systems are larger, more often affiliated with residency programs or medical school, and serve a wealthier, more educated patient population. 10 Correspondingly, CoC-accreditation criteria include minimum case volume standards and provision of diagnostic and therapeutic cancer services either in-house or via referral, which may be facilitated through health system participation. Further, some cancer program types require academic and/or educational components such resident physician training and funded research. 5
Concerns remain that increasing consolidation of the health care industry may shrink volume and raise prices at struggling rural hospitals within large health systems, exacerbating existing disparities in access to quality surgical care for the already uniquely vulnerable patient populations they serve. 11 Our study affirms that these rural hospital patient populations have lower incomes, education levels, and higher unemployment rates—all risk factors for adverse cancer outcomes. Further, rural populations have fewer racial and ethnic minorities. They typically reside in historically segregated areas that experience a higher frequency of hospital closures. 12 The absence of cancer center expertise in rurally and racially marginalized areas may be more critical for rural racial and ethnic minority patients who may have unique cancer care needs.
This study demonstrated a trend toward more health systems with cancer centers having a rural hospital. It is unknown whether these health systems were more likely to acquire a rural hospital, or less likely to close a rural hospital that they acquired. Regardless, when health systems with unique services such as quality cancer care acquire or maintain rural hospitals, they may be better able to address these existing disparities faced by under-resourced and marginalized groups. However, because the overall number of health systems with rural hospitals is low (10%) and our prior work found that a greater proportion of rural hospitals are independent (not in a health system), the overall impact of this strategy is currently limited. 13 Policies that require or incentivize health systems to integrate and maintain rural hospitals may increase equitable access to quality surgical care.
Strengths of this study include the linkage of 2 comprehensive national datasets to understand the interplay of health systems and cancer centers, and analysis of health system-level covariates, which offers a unique insight into the overall contexts of how cancer centers are situated in US health care delivery. Limitations of this study include its cross-sectional methodology, which may not fully capture ongoing shifts in health care markets or cancer center accreditation in which hospitals are regularly changing ownership statuses and potentially gaining or losing accreditation status. We used the AHRQ definition of a health system which is based on criteria for vertical integration and may not include other arrangements between hospitals such as network affiliations and brand sharing. Lastly, we were unable to evaluate the effect of cancer center participation in a health system or health system integration of a cancer center on the quality of surgical care for cancer patients, which will be the focus of future work.
In conclusion, while most health systems include a cancer center, there are notable differences between health systems that do and do not have one with respect to size, academic affiliation, and rural reach. Though health systems with cancer centers trended toward having more rural hospitals, a significant difference was not observed. Nonetheless, integration of rural hospitals into health systems that offer high-quality subspecialty surgical care like cancer centers may be an effective strategy to increase access for rural patients. Policies that incentive and support these types of health systems in maintaining their rural hospital affiliations may be highly effective. Future work should evaluate whether treatment in a health system with a cancer center actually improves the quality of care delivered and should assess differential effects at rural vs non-rural hospitals within the same health systems.
Footnotes
Acknowledgments
Thank you to the Surgery Undergraduate Research Experience program at the University of Alabama at Birmingham.
Author Contributions
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Grant support was provided to Dr Montgomery by the Agency for Healthcare Research and Quality under grant T32 HS013852 and to Dr Broman from the American College of Surgeons, the American Society of Clinical Oncology, and the National Institutes of Health (National Center for Advancing Translational Sciences) on grant KL2 TR003097.
