IMPORTANCE Hospital consolidations have been shown not to improve quality on average. OBJECTIVE To assess a full-integration approach to hospital mergers based on quality metrics in a safety net hospital acquired by an urban academic health system. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study analyzed outcomes for all nonpsychiatric, nonrehabilitation, non-newborn patients discharged between September 1, 2010, and August 31, 2019, at a US safety net hospital that was acquired by an urban academic health system in January 2016. Interrupted time series and statistical process control analyses were used to assess the main outcomes and measures. Data sources included the hospital's electronic health record, Centers for Medicare & Medicaid Services Hospital Compare, and nursing quality reports.EXPOSURES A full-integration approach to the merger that included: (1) early administrative and clinical leadership integration with the academic health system; (2) rapid transition to the academic health system electronic health record; (3) local ownership of quality metrics; (4) system-level goals with real-time actionable analytics through combined dashboards; and (5) implementation of value-based and other analytic-driven interventions. MAIN OUTCOMES AND MEASURESThe primary outcome was in-hospital mortality. Secondary outcomes included 30-day readmission, patient experience, and hospital-acquired conditions. RESULTSThe 122 348 patients in the premerger (September 2010 through August 2016) and the 58 904 patients in the postmerger (September 2016 through August 2019) periods had a mean (SD) age of 55.5 (22.0) years; the total sample of 181 252 patients included 112 191 women (61.9%), the payor mix was majority governmental (144 375 patients [79.7%]), and most admissions were emergent (121 469 patients [67.0%]). There was a 0.71% (95% CI, 0.57%-0.86%) absolute (27% relative) reduction in the crude mortality rate and 0.95% (95% CI, 0.83%-1.12%) absolute (33% relative) in the adjusted rate by the end of the 3-year intervention period. There was no significant improvement in readmission rates after accounting for baseline trends. There were fewer central line infections per 1000 catheter days, fewer catheter-associated urinary tract infections per 1000 discharges, and a higher likelihood of patients recommending the hospital or ranking it 9 or 10. CONCLUSIONS AND RELEVANCEIn this quality improvement study, a hospital merger with a fullintegration approach to consolidation was found to be associated with improvement in quality outcomes.

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This study examined injury and physical fitness outcomes in Basic Combat Training (BCT) during implementation of Physical Readiness Training (PRT). PRT is the U.S. Army's emerging physical fitness training program. An experimental group (EG, n = 1284), which implemented the PRT program, was compared to a control group (CG, n = 1296), which used a traditional BCT physical training program during the 9-week BCT cycle. Injury cases were obtained from recruit medical records and physical fitness was measured using the U.S. Army Physical Fitness Test (APFT, consisting of push-ups, sit-ups and a two-mile run). Injury rates were examined using Cox regression after controlled for initial group differences in demographics, fitness and other variables. Compared to the EG, the adjusted relative risk of a time-loss overuse injury in the CG was 1.5 (95 % confidence interval [CI] = 1.0 - 2.1, p < 0.01) for men and 1.4 (95 %CI = 1.1 - 1.8, p < 0.01) for women. There were no differences between groups for traumatic injuries. On the first administration of the final APFT, the EG had a greater proportion of recruits passing the test than the CG (men: 85 % vs. 81 %, p = 0.04; women: 80 % vs. 70 %, p < 0.01). After all APFT retakes, the EG had significantly fewer APFT failures than the CG among the women (1.6 % vs. 4.6 %, p < 0.01) but not the men (1.6 % vs. 2.8 %, p = 0.18); the gender-combined EG had a higher pass rate (1.6 % vs. 3.7 %, p < 0.01). Overall, the PRT program reduced overuse injuries and allowed a higher success rate on the APFT.

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Injuries and activities associated with injuries were extracted from a retrospective review of the medical records of officers attending the U.S. Army War College during academic years 1999 and 2000 (AY99 and AY00). In AY99, cumulative injury incidence (officers with one or more injuries) was 56%. The next year (AY00), there was command emphasis on injury reduction and education of students on injury prevention strategies. Cumulative injury incidence in AY00 was 44%, significantly lower than in AY99 (p = 0.01, risk ratio [AY99/AY99] = 1.3, 95% confidence interval = 1.1-1.5). Among activities that could be linked to injuries, sports were associated with 41% in AY99 and 45% in AY00. Recommendations for ongoing injury reduction include the following: (1) continued command emphasis and instruction on injury reduction techniques; (2) encouraging the use of semirigid ankle braces to reduce ankle sprains; (3) reducing the number of practice and game sessions in sports activities; (4) encouraging overrunning of second and third base in softball; (5) prohibiting contact with the center line below the net in volleyball; and (6) encouraging medical care providers to record the activity associated with each injury in the medical records.