{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T22:45:59Z","timestamp":1792622759886,"version":"4.5.0"},"reference-count":30,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T00:00:00Z","timestamp":1782777600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"funder":[{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","award":["T32HS000055"],"award-info":[{"award-number":["T32HS000055"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","award":["U19HS024072"],"award-info":[{"award-number":["U19HS024072"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100031022","name":"Center for Cancer Research","doi-asserted-by":"publisher","award":["R01CA255035"],"award-info":[{"award-number":["R01CA255035"]}],"id":[{"id":"10.13039\/100031022","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Med Care Res Rev"],"abstract":"<jats:p>The impact of safety-net hospital (SNH) acquisition by health systems on specialty care delivery remains unclear, with important implications for access and equity. We examined how SNH acquisitions affect oncology service availability, volumes, and patient characteristics among Medicare fee-for-service beneficiaries using claims data from 2008 to 2019. We identified 75 SNH acquisitions from 2011 to 2015 and 151 independently operated SNHs as controls, estimating changes using a weighted stacked event study design. Following acquisition, chemotherapy volumes increased significantly by 99.6 annual claims (95% CI: [21.9, 177.3]), representing an 84% increase from baseline, while advanced imaging, radiation therapy, and cancer-directed surgical volumes showed no significant changes. We observed no changes in service line availability or patient demographics including race and ethnicity, dual eligibility, or age. These findings suggest system integration may lead to selective expansion of scalable or financially favorable oncology services without markedly altering overall service offerings or Medicare populations served by SNHs.<\/jats:p>","DOI":"10.1177\/10775587261453480","type":"journal-article","created":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T11:28:25Z","timestamp":1782818905000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Changes in Oncology Care Provision Following Safety-Net Hospital Acquisition by Health Systems"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5578-5752","authenticated-orcid":false,"given":"Rebecca A.","family":"Bromley-Dulfano","sequence":"first","affiliation":[{"name":"Harvard Medical School, Boston, MA, USA"},{"name":"Stanford University School of Medicine, CA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy D.","family":"Beaulieu","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary Beth","family":"Landrum","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy L.","family":"Keating","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, MA, USA"},{"name":"Brigham and Women\u2019s Hospital, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,6,30]]},"reference":[{"key":"e_1_3_3_2_1","doi-asserted-by":"crossref","unstructured":"America\u2019s Health Care Safety Net: Intact but Endangered. (2000). National Academies Press. https:\/\/doi.org\/10.17226\/9612","DOI":"10.17226\/9612"},{"key":"e_1_3_3_3_1","doi-asserted-by":"crossref","unstructured":"Andreyeva E. Gupta A. Ishitani C. E. Sylwestrzak M. Ukert B. (2023). The corporatization of independent hospitals (Working Paper 31776). National Bureau of Economic Research. https:\/\/doi.org\/10.3386\/w31776","DOI":"10.3386\/w31776"},{"key":"e_1_3_3_4_1","doi-asserted-by":"crossref","unstructured":"Bazzoli G. J. Lee W. Hsieh H.-M. Mobley L. R. (2012). The effects of safety net hospital closures and conversions on patient travel distance to hospital services. Health Services Research 47(1 Pt. 1) 129\u2013150. https:\/\/doi.org\/10.1111\/j.1475-6773.2011.01318.x","DOI":"10.1111\/j.1475-6773.2011.01318.x"},{"key":"e_1_3_3_5_1","doi-asserted-by":"crossref","unstructured":"Bazzoli G. J. Manheim L. M. Waters T. M. (2003). U.S. hospital industry restructuring and the hospital safety net. INQUIRY: The Journal of Health Care Organization Provision and Financing 40(1) 6\u201324. https:\/\/doi.org\/10.5034\/inquiryjrnl_40.1.6","DOI":"10.5034\/inquiryjrnl_40.1.6"},{"key":"e_1_3_3_6_1","doi-asserted-by":"crossref","unstructured":"Beaulieu N. D. Dafny L. S. Landon B. E. Dalton J. B. Kuye I. McWilliams J. M. (2020). Changes in quality of care after hospital mergers and acquisitions. New England Journal of Medicine 382(1) 51\u201359. https:\/\/doi.org\/10.1056\/NEJMsa1901383","DOI":"10.1056\/NEJMsa1901383"},{"key":"e_1_3_3_7_1","doi-asserted-by":"crossref","unstructured":"Chan C. Lopez A. Castaneda G. Bhuket T. Liu B. Yee S. Irwin D. Wong R. J. (2017). Black patients with colorectal cancer have more advanced cancer stage at time of diagnosis: A community-based safety-net hospital experience. Journal of Community Health 42(4) 724\u2013729. https:\/\/doi.org\/10.1007\/s10900-016-0309-0","DOI":"10.1007\/s10900-016-0309-0"},{"key":"e_1_3_3_8_1","unstructured":"Characteristics of Safety-Net Hospitals 2014 #213. (n.d.). https:\/\/hcup-us.ahrq.gov\/reports\/statbriefs\/sb213-Safety-Net-Hospitals-2014.jsp"},{"key":"e_1_3_3_9_1","doi-asserted-by":"crossref","unstructured":"Chatterjee P. Sommers B. D. Maddox K. E. J. (2020). Essential but undefined\u2014Reimagining how policymakers identify safety-net hospitals. New England Journal of Medicine 383(27) 2593\u20132595. https:\/\/doi.org\/10.1056\/NEJMp2030228","DOI":"10.1056\/NEJMp2030228"},{"key":"e_1_3_3_10_1","unstructured":"Common Cancer Sites\u2014Cancer Stat Facts. (n.d.). SEER. https:\/\/seer.cancer.gov\/statfacts\/html\/common.html"},{"key":"e_1_3_3_11_1","doi-asserted-by":"crossref","unstructured":"Conti R. M. Nikpay S. S. Buntin M. B. (2019). Revenues and profits from Medicare patients in hospitals participating in the 340B drug discount program 2013-2016. JAMA Network Open 2(10) Article e1914141. https:\/\/doi.org\/10.1001\/jamanetworkopen.2019.14141","DOI":"10.1001\/jamanetworkopen.2019.14141"},{"key":"e_1_3_3_12_1","doi-asserted-by":"crossref","unstructured":"Crown A. Ramiah K. Siegel B. Joseph K.-A. (2022). The role of safety-net hospitals in reducing disparities in breast cancer care. Annals of Surgical Oncology 29 4067\u20134075. https:\/\/doi.org\/10.1245\/s10434-022-11576-3","DOI":"10.1245\/s10434-022-11576-3"},{"key":"e_1_3_3_13_1","doi-asserted-by":"crossref","unstructured":"Cutler D. M. Scott Morton F. (2013). Hospitals market share and consolidation. JAMA 310(18) 1964\u20131970. https:\/\/doi.org\/10.1001\/jama.2013.281675","DOI":"10.1001\/jama.2013.281675"},{"key":"e_1_3_3_14_1","unstructured":"Fact Sheet: Hospital Mergers and Acquisitions Can Expand and Preserve Access to Care.(2025 March 31). AHA. https:\/\/www.aha.org\/fact-sheets\/2023-03-16-fact-sheet-hospital-mergers-and-acquisitions-can-expand-and-preserve-access-care"},{"key":"e_1_3_3_15_1","doi-asserted-by":"crossref","unstructured":"Goding Sauer A. Siegel R. L. Jemal A. Fedewa S. A. (2019). Current prevalence of major cancer risk factors and screening test use in the United States: Disparities by education and race\/ethnicity. Cancer Epidemiology Biomarkers & Prevention: A Publication of the American Association for Cancer Research Cosponsored by the American Society of Preventive Oncology 28(4) 629\u2013642. https:\/\/doi.org\/10.1158\/1055-9965.EPI-18-1169","DOI":"10.1158\/1055-9965.EPI-18-1169"},{"key":"e_1_3_3_16_1","unstructured":"Health Systems and Provider Database (HSPD) Methodology\u2014Data Resources. (n.d.). NBER. https:\/\/www.nber.org\/programs-projects\/projects-and-centers\/measuring-clinical-and-economic-outcomes-associated-delivery-systems\/health-systems-and-provider-database-hspd-methodology-data-resources"},{"key":"e_1_3_3_17_1","doi-asserted-by":"crossref","unstructured":"Hefner J. L. Hogan T. H. Opoku-Agyeman W. Menachemi N. (2021). Defining safety net hospitals in the health services research literature: A systematic review and critical appraisal. BMC Health Services Research 21(1) Article 1. https:\/\/doi.org\/10.1186\/s12913-021-06292-9","DOI":"10.1186\/s12913-021-06292-9"},{"key":"e_1_3_3_18_1","doi-asserted-by":"crossref","unstructured":"Henke R. M. Fingar K. R. Jiang H. J. Liang L. Gibson T. B. (2021). Access to obstetric behavioral health and surgical inpatient services after hospital mergers in rural areas. Health Affairs (Project Hope) 40(10) 1627\u20131636. https:\/\/doi.org\/10.1377\/hlthaff.2021.00160","DOI":"10.1377\/hlthaff.2021.00160"},{"key":"e_1_3_3_19_1","doi-asserted-by":"crossref","unstructured":"Jiang H. J. Fingar K. R. Liang L. Henke R. M. Gibson T. P. (2021). Quality of care before and after mergers and acquisitions of rural hospitals. JAMA Network Open 4(9) Article e2124662. https:\/\/doi.org\/10.1001\/jamanetworkopen.2021.24662","DOI":"10.1001\/jamanetworkopen.2021.24662"},{"key":"e_1_3_3_20_1","doi-asserted-by":"crossref","unstructured":"Mariani M. Sisti L. G. Isonne C. Nardi A. Mete R. Ricciardi W. Villari P. De Vito C. Damiani G. (2022). Impact of hospital mergers: A systematic review focusing on healthcare quality measures. European Journal of Public Health 32(2) 191\u2013199. https:\/\/doi.org\/10.1093\/eurpub\/ckac002","DOI":"10.1093\/eurpub\/ckac002"},{"key":"e_1_3_3_21_1","unstructured":"Oyeka O. Ullrich F. Shane D. Mueller K. (n.d.). Changes in service offerings post-system affiliation in rural hospitals. https:\/\/www.ruralhealthresearch.org\/publications\/1566"},{"key":"e_1_3_3_22_1","doi-asserted-by":"crossref","unstructured":"Perlow H. K. Ramey S. J. Silver B. Kwon D. Chinea F. M. Samuels S. E. Samuels M. A. Elsayyad N. Yechieli R. (2018). Assessment of oropharyngeal and laryngeal cancer treatment delay in a private and safety net hospital system. Otolaryngology\u2013Head and Neck Surgery 159(3) 484\u2013493. https:\/\/doi.org\/10.1177\/0194599818768795","DOI":"10.1177\/0194599818768795"},{"key":"e_1_3_3_23_1","doi-asserted-by":"crossref","unstructured":"Popescu I. Fingar K. R. Cutler E. Guo J. Jiang H. J. (2019). Comparison of 3 safety-net hospital definitions and association with hospital characteristics. JAMA Network Open 2(8) Article e198577. https:\/\/doi.org\/10.1001\/jamanetworkopen.2019.8577","DOI":"10.1001\/jamanetworkopen.2019.8577"},{"key":"e_1_3_3_24_1","unstructured":"RAND Policy Insights. (n.d.). What have we learned about safety net providers and integrated care? https:\/\/www.rand.org\/health-care\/centers\/health-system-performance\/what-have-we-learned\/safety-net.html"},{"key":"e_1_3_3_25_1","doi-asserted-by":"crossref","unstructured":"Satiani B. Way D. P. Hoyt D. B. Ellison E. C. (2025). Systematic review of integration strategies across the us healthcare system: Assessment of price cost and quality of care. Journal of the American College of Surgeons 240(5) 758. https:\/\/doi.org\/10.1097\/XCS.0000000000001229","DOI":"10.1097\/XCS.0000000000001229"},{"key":"e_1_3_3_26_1","doi-asserted-by":"crossref","unstructured":"Sun L. Abraham S. (2021). Estimating dynamic treatment effects in event studies with heterogeneous treatment effects. Journal of Econometrics 225(2) 175\u2013199. https:\/\/doi.org\/10.1016\/j.jeconom.2020.09.006","DOI":"10.1016\/j.jeconom.2020.09.006"},{"key":"e_1_3_3_27_1","doi-asserted-by":"crossref","unstructured":"Wang E. Arnold S. Jones S. Zhang Y. Volpicelli F. Weisstuch J. Horwitz L. Rudy B. (2022). Quality and safety outcomes of a hospital merger following a full integration at a safety net hospital. JAMA Network Open 5(1) Article e2142382. https:\/\/doi.org\/10.1001\/jamanetworkopen.2021.42382","DOI":"10.1001\/jamanetworkopen.2021.42382"},{"key":"e_1_3_3_28_1","doi-asserted-by":"crossref","unstructured":"Wing C. Freedman S. M. Hollingsworth A. (2024). Stacked difference-in-differences (Working Paper 32054). National Bureau of Economic Research. https:\/\/doi.org\/10.3386\/w32054","DOI":"10.3386\/w32054"},{"key":"e_1_3_3_29_1","doi-asserted-by":"crossref","unstructured":"Winkelman T. N. A. Vickery K. D. (2019). Refining the definition of US safety-net hospitals to improve population health. JAMA Network Open 2(8) Article e198562. https:\/\/doi.org\/10.1001\/jamanetworkopen.2019.8562","DOI":"10.1001\/jamanetworkopen.2019.8562"},{"key":"e_1_3_3_30_1","doi-asserted-by":"crossref","unstructured":"Wood C. Chen X. Schpero W. Chatterjee P. (2024). Acquisitions of safety-net hospitals from 2016\u20132021: A case series. Health Affairs Scholar 2(6) qxae056. https:\/\/doi.org\/10.1093\/haschl\/qxae056","DOI":"10.1093\/haschl\/qxae056"},{"key":"e_1_3_3_31_1","doi-asserted-by":"crossref","unstructured":"Zaorsky N. G. Khunsriraksakul C. Acri S. L. Liu D. J. Ba D. M. Lin J. L. Liu G. Segel J. E. Drabick J. J. Mackley H. B. Leslie D. L. (2021). Medical service use and charges for cancer care in 2018 for privately insured patients younger than 65 years in the US. JAMA Network Open 4(10) Article e2127784. https:\/\/doi.org\/10.1001\/jamanetworkopen.2021.27784","DOI":"10.1001\/jamanetworkopen.2021.27784"}],"container-title":["Medical Care Research and Review"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/10775587261453480","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/10775587261453480","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/10775587261453480","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T11:16:40Z","timestamp":1783077400000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/10775587261453480"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,30]]},"references-count":30,"alternative-id":["10.1177\/10775587261453480"],"URL":"https:\/\/doi.org\/10.1177\/10775587261453480","relation":{},"ISSN":["1077-5587","1552-6801"],"issn-type":[{"value":"1077-5587","type":"print"},{"value":"1552-6801","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,30]]},"article-number":"10775587261453480"}}