Characterization of US Hospital Advertising and Association With Hospital Performance, 2008-2016

IMPORTANCE: Hospital advertising has been touted as a tool to improve consumer decision-making, but little is known about its association with objective measures of hospital quality. OBJECTIVE: To document recent trends in hospital advertising in the US and examine the association between concurrent measures of hospital advertising and quality. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study of all general acute care hospitals operating in the US between January 2008 and December 2016. Data were analyzed from December 6, 2019, to July 15, 2020. EXPOSURE: Annualized advertising spending for each hospital as measured by a market research firm. MAIN OUTCOMES AND MEASURES: Four composites of hospital performance from the Centers for Medicare & Medicaid Services Hospital Compare database were used: risk-standardized mortality rate, risk-standardized readmission rate, Consumer Assessment of Healthcare Providers & Systems (CAHPS) Overall Patient Experience Rating (scale of 1-5; higher scores indicate a more positive patient experience rating), and overall 5-star rating. Linear models adjusted for hospital bed size, hospital revenue, and geographic census region. RESULTS: The study sample included, on average, 4569 general acute care hospitals per year between 2008 and 2016. During this time, approximately half of acute care hospitals (2239 of 4569 [49%]) advertised their services to consumers and spent a total of $3.39 billion. Relative to hospitals that never advertised, advertising hospitals were more likely to be nonprofit facilities (mean [SD], 66% [47%] vs 51% [50%]; P < .001), had larger bed sizes (mean [SD], 234.3 [210.7] beds vs 84.8 [110.6] beds; P < .001), and had higher net incomes (mean [SD], $17 800 000 [$49 000 000] vs $134 099 [$51 600 000]; P < .001). There was no observed association between hospital advertising and performance. For example, hospitals that advertised had a mean (SD) CAHPS 5-star rating of 3.2 (0.9) stars compared with 3.3 (1.0) stars among hospitals that did not advertise, an insignificant difference (P = .92). We observed no difference in performance between advertising and nonadvertising hospitals in 30-day readmission rates (mean [SD], 15.5% [0.8%] vs 15.6% [1.0%]; P = .25), mortality rates (mean [SD], 12.7% [4.0%] vs 12.0% [4.1%]; P = .46), and overall 5-star hospital ratings (mean [SD], 3.1 [0.8] stars vs 3.0 [0.9] stars; P = .50). A significant difference was observed in adjusted mortality rates across terciles of advertising spending, with lower mortality rates for the hospitals with higher ad spending (2016, mean [SD] mortality composite for hospitals in the highest tercile, 11.2% [4.2%] vs hospitals in the middle tercile, 12.0% [3.8%], and for hospitals in the lowest tercile, 12.7% [4.1%]; P = .003). CONCLUSIONS AND RELEVANCE: The results of this cross-sectional study suggest that the amount hospitals spent on direct-to-consumer advertising was not associated with publicly reported measures of hospital quality; instead, hospital advertising spending was higher for financially stable hospitals with higher net incomes.