A new study by researchers at Yale has found that many people feel less motivated to travel to top-ranked cancer hospitals for surgery when smaller local hospitals share their brand.

The research team attempted to determine how patients perceive the safety and quality of complex cancer surgeries performed at top cancer hospitals compared to those performed at their smaller affiliate hospitals. Led by Daniel Boffa, a professor of thoracic surgery at the Yale School of Medicine, the study was published on Oct. 11 in the Annals of Surgical Oncology.

“Prominent hospitals that are sharing their brands with smaller hospitals need to ensure that the outcomes are the same across all hospitals bearing their name because the public is trusting [that] they are,” Boffa said.

The team found that approximately half of the 1,010 surveyed individuals did not distinguish between the quality of surgical care at top-ranked cancer hospitals from that of their affiliates. Specifically, respondents believed that surgical safety, guideline compliance and cure rates would be the same across both types of hospitals.

Whereas 85 percent of respondents initially indicated that they would travel an hour for complex surgery at a larger cancer hospital over a smaller local one, 31 percent of these individuals changed their preference to the smaller hospital if it was affiliated with a top-ranked hospital.

Boffa said that he was motivated to conduct the study after a person close to him received and died after surgery at a small hospital affiliated with a prominent one. It was clear to him that the hospital was unprepared to deal with potential complications of the surgery, he explained, but the patient had chosen the hospital because it shared the brand, causing them to believe that the level of care would be the same.

Brand-sharing among hospitals is a new paradigm that has developed within the last decade, according to James Yu, a School of Medicine professor of therapeutic radiology. Cancer centers are motivated to affiliate with smaller hospitals because it leads to more profit and also spreads out administrative costs and centralizes supplies. From an academic standpoint, it is beneficial to have more patients enrolled in clinical trials and studies, which are important academic endeavors, Yu said.

These “satellite” hospitals, in turn, are motivated to affiliate with larger cancer hospitals for their competitive advantage, said Yu, who was not involved in the research.

Boffa added that for smaller hospitals trying to create brand recognition, affiliating with prominent cancer hospitals is an effective advertising strategy, as the study shows.

According to Heather Yeo, a professor of surgery and public health at Weill Cornell Medical College, larger hospitals often have a greater pool of resources, offer more services and can also provide specialized and complex care for rare diseases. Collaborating with smaller hospitals can combine faculty and resources, streamline protocols and improve efficiency, Yeo said, who was not involved in the research.

While the benefits of brand sharing for hospitals are clear, the benefits for patients are less documented, Yu said. In theory, patients at satellite hospitals have access to top cancer specialists, standardized treatment, clinical trials and tumor boards, in which expert physicians review and discuss complex cancer cases. But whether this is actually the case has not been researched, he norws.

“We know hospitals make more money the bigger they get,” Yu said. “What we don’t know is whether this is beneficial to the patients — whether they do as well at the branded satellites. That’s an interesting question to investigate.”

Yu explained that in the case of the radiology department, affiliates of Yale New Haven Hospital provide outstanding care. But he is unsure of the quality of care at other affiliate hospitals, because there is not the same level of oversight within other departments at Yale New Haven. To maintain a uniform sense of quality, which becomes increasingly difficult as the institution grows, there needs to be either clear institutional culture and leadership, or a systematic set of oversight and quality control, Yu said.

Because of this difficulty, the level of connection between the parent institution and the affiliates, as well as the impact that the brand sharing will have on the level of care, should be transparent to the public, Yu noted.

According to Boffa, the situation is particularly dire because there are currently no guidelines or mandates that inform the public of these potential problems, and the affiliates are not obligated to inform their patients if they lack the resources to provide the care they need.

“Policymakers should consider the impact that the unrestricted promotion of hospital affiliation status has had on the perceived safety across health systems and determine if perceptions align with reality,” Boffa said.

Based on the research’s findings, he said, it is up to the larger hospitals to investigate the quality of care at affiliates and make rules regarding which types of patients affiliates are equipped to treat.

Boffa noted, however, that there are practical limitations involved in enforcing these standards. Larger hospitals lack the resources to care for every patient in their area of expertise, and not every patient has the resources to travel to these larger hospitals to receive care.

There are currently 70 cancer centers designated by the National Cancer Institute, located in 36 states and the District of Columbia, according to the National Cancer Institute.

Eui Young Kimeuiyoung.kim@yale.edu