Date of Award

January 2022

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Nihar Desai


There is substantial hospital-level variation in the quality of healthcare delivered in the United States. Although patients now have greater access to public reporting of hospital quality than ever before, many individual, geographic, and structural factors limit patient choice. The degree to which hospital quality aligns with hospital market share is largely unknown.

Using public performance measure score and volume data from CMS’s Hospital Care Compare, we assessed the association between publicly reported hospital performance scores and hospital market share for elective, semi-elective, and non-elective procedures.

Using logistic regression, we found a significant association between hospitals’ risk-adjusted complication rate and their market share with a modest effect size for hip/knee replacement complication (-4.2; 95% CI: -6.56, -1.88; p<.001) and acute myocardial infarction (AMI) readmission (-1.7; 95% CI: -3.10, -0.25; p=0.02). We did not find a significant association for AMI mortality or coronary artery bypass graft (CABG) readmission or mortality.

These findings highlight a continued need to better align where patients receive care and the quality of care they receive for non-elective and semi-elective conditions/procedures. They support efforts to increase transparency and usability of hospital quality reporting, reduce constraints on patient choice, and increase the capacity and geographic distribution of high-quality hospitals.

Value-based payment and healthcare delivery models are essential to efforts to advance the alignment of hospital quality and market share given their incentives around clinical outcomes. Expanding the implementation of these models could improve access to high-quality care. However, early evidence suggests that the structure of many of these programs may disincentivize providers from caring for more complex patients and worsen existing racial and socioeconomic health disparities, indicating an urgent need for refinement and optimization.


This is an Open Access Thesis.

Open Access

This Article is Open Access