Associations Between Integration and Patient Experience in Hospital-Based Health Systems: An Exploration of Horizontal and Vertical Forms of Integration.

GOAL: The U.S. hospital sector is experiencing record levels of integration, with more than half of U.S. physicians and nearly three quarters of all hospitals affiliated with one of slightly more than 630 health systems. However, there is growing evidence to suggest that health system integration is associated with more expensive and lower quality care. The goal of this research is to explore the associations between forms of health system integration and hospital patient experience scores. METHODS: A cross-section of data for the year 2019 was assembled and analyzed from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience survey. Data from the Compendium of US Health Systems, published by the Agency for Healthcare Research and Quality (AHRQ), and the American Hospital Association (AHA) Annual Survey were used to obtain independent variables and hospital-level covariates. A series of multivariable regressions was used to explore the associations between forms of health system integration and hospital patient experience scores across three domains: overall impression of the hospital; experiences with staff; and the hospital environment. Forms of both horizontal integration (i.e., number of hospitals owned by hospital-based health systems) and vertical integration (i.e., physician-hospital integration, nursing home ownership, accountable care organization [ACO] participation, group purchasing, contract management, offering insurance products, and investor ownership) were explored. PRINCIPAL FINDINGS: Although horizontal integration was not associated with any meaningful differences in patient experience scores, health systems with physician-hospital integration were associated with overall impression scores that were 2 percentage points higher than systems without physician integration. Similarly, contract management and membership in a group purchasing organization were associated with overall impression and environment scores that were 2 to 3 percentage points higher than hospitals that did not engage in those forms of integration. By contrast, investor ownership was associated with a 5% lower score for overall patient experience compared with other forms of ownership. PRACTICAL APPLICATIONS: The findings of this study suggest that hospitals in more vertically integrated systems may have higher patient experience scores than independent hospitals and those that belong exclusively to horizontally integrated systems. Thus, there are elements of vertical integration that could benefit patients and be worth pursuing. Conversely, higher degrees of horizontal integration in the form of multihospital ownership may not be of any benefit to patients and should be pursued with caution.

The impact of accountable care organization participation on hospital patient experience.

BACKGROUND: Accountable care organizations (ACOs) are being implemented rapidly across the Unites States. Previous studies indicated an increasing number of hospitals have participated in ACOs. However, little is known about how ACO participation could influence hospitals' performance. PURPOSE: This study aims to examine the impact of Medicare ACO participation on hospitals' patient experience. METHODOLOGY/APPROACH: Difference-in-difference analyses were conducted to compare 10 patient experience measures between hospitals participating in Medicare ACOs and those not participating. RESULTS: In general, hospitals participating in Pioneer ACOs had significantly improved scores on nursing communication and doctor communication. Shared Savings Program (SSP) ACO participation did not show significant improvement of patient experience. Subgroup analyses indicate that, for hospitals in the middle and top tertile groups in terms of baseline experience, Pioneer ACO and SSP ACO participation was associated with better patient experience. For hospitals in the bottom tertile, Pioneer ACO and SSP ACO participation had no association with patient experience. CONCLUSION: ACO participation improved some aspects of patient experience among hospitals with prior good performance. However, hospitals with historically poor performance did not benefit from ACO participation. PRACTICE IMPLICATIONS: Prior care coordination and quality improvement experience position Medicare ACOs for greater success in terms of patient experience. Hospital leaders need to consider the potential negative consequences of ACO participation and the hospital's preparedness for care coordination.

Assessing Trends in Hospital System Structures From 2008 to 2015.

BACKGROUND: The Affordable Care Act introduced a major systematic change aimed to promote coordination across the care continuum. Yet, it remains unknown the extent to which hospital system structures have changed following the Affordable Care Act. The structure of hospital systems has important implications for the cost, quality, and accessibility of health services. OBJECTIVES: To assess trends in the structures of hospital systems. RESEARCH DESIGN: We aggregated data from the American Hospital Association (AHA) Annual Survey to the system level. Using a panel of hospital systems from 2008 to 2015, we assessed trends in the number of hospital systems, their size, ownership characteristics, geospatial arrangements, and integration with outpatient services. RESULTS: In the period 2008-2015, there was an increasing percentage of hospitals that were system affiliated as well as growth in the number of hospital systems. A greater percentage of hospital systems that were organized as moderately centralized systems transitioned to centralized systems than to decentralized systems (19.8% vs. 4.7%; P<0.001). In terms of geospatial arrangement, a greater percentage of hub-and-spoke systems moved to a regional design than to national systems (20.0% vs. 8.2%; P<0.05). An increasing trend over time toward greater integration with outpatient services was found in a measure of total system level integration with outpatient services. CONCLUSIONS: Our findings suggest that hospital systems may be moving toward more regional designs. In addition, the trend of increasing integration offered across hospital systems overall, and as portion of total integration, suggests that systems may be increasing their services along the continuum of care.

Comparison of objective measures and patients' perceptions of quality of services in government health facilities in the Democratic Republic of Congo.

OBJECTIVE: Examine the relationship between patients' perceptions of quality and the objective level of quality at government health facilities, and determine whether the pre-existing attitudes and beliefs of patients regarding health services interfere with their ability to accurately assess quality of care. DESIGN: Cross-sectional, visit-level analysis. SETTING: Three regions (Nord-Ubangi, Kasai/Kasai-Central and Maniema/Tshopo) of the Democratic Republic of Congo. PARTICIPANTS: Data related to the inpatient and outpatient visits to government health facilities made by all household members who were included in the survey was used for the analysis. Data were collected from patients and the facilities they visited. MAIN OUTCOME MEASURES: Patients' perceptions of the level of quality related to availability of drugs and equipment; patient-centeredness and safety serve compared with objective measures of quality. RESULTS: Objective measures and patient perceptions of the drug supply were positively associated (ß = 0.16, 95% CI = 0.03, 0.28) and of safety were negatively associated (ß = -0.12, 95% CI = -0.23, -0.01). Several environmental factors including facility type, region and rural/peri-urban setting were found to be significantly associated with respondents' perceptions of quality across multiple outcomes. CONCLUSIONS: Overall, patients are not particularly accurate in their assessments of quality because their perceptions are impacted by their expectations and prior experience. Future research should examine whether improving patients' knowledge of what they should expect from health services, and the transparency of the facility's quality data can be a strategy for improving the accuracy of patients' assessments of the quality of the health services, particularly in low-resourced settings.

The Association Between Hospital ACO Participation and Readmission Rates.

EXECUTIVE SUMMARY: Accountable care organizations (ACOs) were established as part of the Affordable Care Act to reduce costs, improve the patient experience, and increase the quality of care. While previous studies have examined the quality, costs, and patient experience among ACOs, the relationship between hospitals' ACO participation and its effects on hospitals' performance have been incompletely characterized. The main purpose of this study is to measure the association between hospitals' participation in Medicare Pioneer and Shared Savings Program (SSP) ACOs and readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. We employed a cross-sectional design using hospital readmission data from Hospital Compare, hospital characteristics data from the American Hospital Association Annual Survey, and market environmental data from Area Health Resource Files. We employed a descriptive analysis and linear regressions to examine how ACO participation is associated with readmission rates in these three conditions.Overall, we found that SSP ACO participation is significantly associated with a decrease in the HF readmission rate (ß = 0.320, p < .05), while Pioneer ACO participation is not associated with a decrease in the HF readmission rate. In addition, we found no evidence that Pioneer ACO or SSP ACO participation is associated with reduced readmission rates for AMI or pneumonia. This study concluded that Medicare ACO programs have limited effects on readmission rates. Policy makers should consider adjusting the accountable care model to improve the quality of care.

Exploring the barriers to rigorous monitoring and evaluation of health systems strengthening activities: qualitative evidence from international development partners.

The number of health systems strengthening (HSS) programs has increased in the last decade. However, a limited number of studies providing robust evidence for the value and impact of these programs are available. This study aims to identify knowledge gaps and challenges that impede rigorous monitoring and evaluation (M&E) of HSS, and to ascertain the extent to which these efforts are informed by existing technical guidance. Interviews were conducted with HSS advisors at United States Agency for International Development-funded missions as well as senior M&E advisors at implementing partner and multilateral organizations. Findings showed that mission staff do not use existing technical resources, either because they do not know about them or do not find them useful. Barriers to rigorous M&E included a lack suitable of indicators, data limitations, difficulty in demonstrating an impact on health, and insufficient funding and resources. Consensus and collaboration between international health partners and local governments may mitigate these challenges. Copyright © 2016 John Wiley & Sons, Ltd.

Measuring Patient Satisfaction's Relationship to Hospital Cost Efficiency: Can Administrators Make a Difference?

OBJECTIVE: The aim of this study was to assess the ability and means by which hospital administrators can influence patient satisfaction and its impact on costs. DATA SOURCES: Data are drawn from the American Hospital Association's Annual Survey of Hospitals, federally collected Hospital Cost Reports, and Medicare's Hospital Compare. STUDY DESIGN: Stochastic frontier analyses (SFA) are used to test the hypothesis that the patient satisfaction-hospital cost relationship is primarily a latent "management effect." The null hypothesis is that patient satisfaction measures are main effects under the control of care providers rather than administrators. PRINCIPLE FINDINGS: Both SFA models were superior to the standard regression analysis when measuring patient satisfaction's relationship to hospitals' cost efficiency. The SFA model with patient satisfaction measures treated as main effects, rather than "latent, management effects," was significantly better comparing the log-likelihood statistics. Higher patient satisfaction scores on the environmental quality and provider communication dimensions were related to lower facility costs. Higher facility costs were positively associated with patients' overall impressions (willingness to recommend and overall satisfaction), assessments of medication and discharge instructions, and ratings of caregiver responsiveness (pain control and help when called). CONCLUSIONS: In the short term, managers have a limited ability to influence patient satisfaction scores, and it appears that working through frontline providers (doctors and nurses) is critical to success. In addition, results indicate that not all patient satisfaction gains are cost neutral and there may be added costs to some forms of quality. Therefore, quality is not costless as is often argued.

Hospital Adoption of Health Information Technology to Support Public Health Infrastructure.

CONTEXT: Health information technology (IT) has the potential to improve the nation's public health infrastructure. In support of this belief, meaningful use incentives include criteria for hospitals to electronically report to immunization registries, as well as to public health agencies for reportable laboratory results and syndromic surveillance. Electronic reporting can facilitate faster and more appropriate public health response. However, it remains unclear the extent that hospitals have adopted IT for public health efforts. OBJECTIVE: To examine hospital adoption of IT for public health and to compare hospitals capable of using and not using public health IT. DESIGN: Cross-sectional design with data from the 2012 American Hospital Association annual survey matched with data from the 2013 American Hospital Association Information Technology Supplement. Multivariate logistic regression was used to compare hospital characteristics. Inverse probability weights were applied to adjust for selection bias because of survey nonresponse. PARTICIPANTS: All acute care general hospitals in the United States that matched across the surveys and had complete data available were included in the analytic sample. MAIN OUTCOME MEASURES: Three separate outcome measures were used: whether the hospital could electronically report to immunization registries, whether the hospital could send electronic laboratory results, and whether the hospital can participate in syndromic surveillance. RESULTS: A total of 2841 hospitals met the inclusion criteria. Weighted results show that of these hospitals, 62.7% can electronically submit to immunization registries, 56.6% can electronically report laboratory results, and 54.4% can electronically report syndromic surveillance. Adjusted and weighted results from the multivariate analyses show that small, rural hospitals and hospitals without electronic health record systems lag in the adoption of public health IT capabilities. CONCLUSION: While a majority of hospitals are using public health IT, the infrastructure still has significant room for growth. Differences in hospitals' adoption of public health IT may exacerbate existing health disparities.

Assessing the relationship between patient safety culture and EHR strategy.

Purpose - The purpose of this paper is to explore the relationship between hospitals' electronic health record (EHR) adoption characteristics and their patient safety cultures. The "Meaningful Use" (MU) program is designed to increase hospitals' adoption of EHR, which will lead to better care quality, reduce medical errors, avoid unnecessary cost, and promote a patient safety culture. To reduce medical errors, hospital leaders have been encouraged to promote safety cultures common to high-reliability organizations. Expecting a positive relationship between EHR adoption and improved patient safety cultures appears sound in theory, but it has yet to be empirically demonstrated. Design/methodology/approach - Providers' perceptions of patient safety culture and counts of patient safety incidents are explored in relationship to hospital EHR adoption patterns. Multi-level modeling is employed to data drawn from the Agency for Healthcare Research and Quality's surveys on patient safety culture (level 1) and the American Hospital Association's survey and healthcare information technology supplement (level 2). Findings - The findings suggest that the early adoption of EHR capabilities hold a negative association to the number of patient safety events reported. However, this relationship was not present in providers' perceptions of overall patient safety cultures. These mixed results suggest that the understanding of the EHR-patient safety culture relationship needs further research. Originality/value - Relating EHR MU and providers' care quality attitudes is an important leading indicator for improved patient safety cultures. For healthcare facility managers and providers, the ability to effectively quantify the impact of new technologies on efforts to change organizational cultures is important for pinpointing clinical areas for process improvements.

Hospital characteristics associated with achievement of meaningful use.

The objective of this study was to identify factors associated with hospitals that achieved the Medicare meaningful use incentive thresholds for payment under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. We employed a cross-sectional design using data from the 2011 American Hospital Association Annual Survey, including the Information Technology Supplement; the Centers for Medicare & Medicaid Services report of hospitals receiving meaningful use payments; and the Health Resources and Services Administration's Area Resource File. We used a lagged value from 2010 to determine electronic health record (EHR) adoption. Our methods were a descriptive analysis and logistic regression to examine how various hospital characteristics are associated with the achievement of Medicare meaningful use incentives. Overall, 1,769 (38%) of 4,683 potentially eligible hospitals achieved meaningful use incentive thresholds by the end of 2012. Characteristics associated with organizations that received incentive payments were having an EHR in place in 2010, having a larger bed size, having a single health information technology vendor, obtaining Joint Commission accreditation, operating under for-profit status, having Medicare share of inpatient days in the middle two quartiles, being eligible for Medicaid incentives, and being located in the Middle Atlantic or South Atlantic census region. Characteristics associated with not receiving incentive payments were being a member of a hospital system and being located in the Mountain or Pacific census region. Thus far, little evidence suggests that the HITECH incentive program has enticed hospitals without an EHR system to adopt meaningful use criteria. Policy makers should consider modifying the incentive program to accelerate the adoption of and meaningful use in hospitals without EHRs.

Factors related to health information exchange participation and use.

This study examines factors facilitating and delaying participation and use of the Health Information Exchange (HIE) in Louisiana. Semi-structured qualitative interviews were conducted with health care representatives throughout the state. Findings suggest that Meaningful Use requirements are a critical factor influencing the decision to participate in the HIE, specifically the mandate that hospitals be able to electronically transfer summary of care documents. Creating buy-in within a few large hospital networks legitimized the HIE and hastened interest in those markets. Fees charged by electronic health record (EHR) vendors to develop HIE interfaces have been prohibitive. Funding from the federal incentive program is intended to offset the costs associated with EHR implementation and increase the likelihood that HIEs can provide value to the population; however, costs and time delays of EHR interface development may be key barriers to fully integrated HIEs. State HIEs may benefit from targeted involvement of state health care leaders who can champion the potential value of the HIE.

Patient satisfaction scores and their relationship to hospital website quality measures.

Hospitals and health systems are using web-based and social media tools to market themselves to consumers with increasingly sophisticated strategies. These efforts are designed to shape the consumers' expectations, influence their purchase decisions, and build a positive reputation in the marketplace. Little is known about how these web-based marketing efforts are taking form and if they have any relationship to consumers' satisfaction with the services they receive. The purpose of this study is to assess if a relationship exists between the quality of hospitals' public websites and their aggregated patient satisfaction ratings. Based on analyses of 1,952 U.S. hospitals, our results show that website quality is significantly and positively related to patients' overall rating of the hospital and their intention to recommend the facility to others. The potential for web-based information sources to influence consumer behavior has important implications for policymakers, third-party payers, health care providers, and consumers.

Is electronic health record use associated with patient satisfaction in hospitals?

PURPOSE: The aim of this study was to examine the relationship between hospital electronic health record (EHR) use and patient satisfaction. DATA SOURCES/STUDY SETTING: We used EHR and other data from the American Hospital Association and Area Resource File as well as all 10 measures of patient satisfaction from the Hospital Compare data from 2008. METHODOLOGY/APPROACH: We used a retrospective cross-sectional approach and control for potential selection bias with propensity score matching. Ten regression models were used to measure the relationship between EHR use and patient satisfaction. Of these, 3 of the 10 patient satisfaction items were hypothesized to be amenable by EHR automation; the remaining 7 measures served as counterfactuals. FINDINGS: Electronic health record use was positively and significantly associated with the 3 hypothesized measures and none of the counterfactual measures of patient satisfaction. The three measures associated with EHR use included (a) whether the staff gave the patient information on what to do for recovery at home, (b) whether the patient would rate the hospital as a 9 or a 10, and (c) whether the patient would recommend the hospital. The significant relationships persisted with propensity score adjustments. PRACTICE IMPLICATIONS: Electronic health record use is positively associated with 3 of 10 measures of patient satisfaction. Policy and decision makers interested in EHR adoption should also consider the potential impact that such adoption can have on patient satisfaction.

Market factors and electronic medical record adoption in medical practices.

BACKGROUND: Previous studies identified individual or practice factors that influence practice-based physicians' electronic medical record (EMR) adoption. Less is known about the market factors that influence physicians' EMR adoption. PURPOSE: The aim of this study was to explore the relationship between environmental market characteristics and physicians' EMR adoption. METHODS: The Health Tracking Physician Survey 2008 and Area Resource File (2008) were combined and analyzed. Binary logistic regression was used to examine the relationship between three dimensions of the market environment (munificence, dynamism, and complexity) and EMR adoption controlling for several physician and practice characteristics. RESULTS: In a nationally representative sample of 4,720 physicians, measures of market dynamism including increases in unemployment, odds ratio (OR) = 0.95, 95% confidence interval (CI) [0.91, 0.99], or poverty rates, OR = 0.93, 95% CI [0.89, 0.96], were negatively associated with EMR adoption. Health maintenance organization penetration, OR = 3.01, 95% CI [1.49, 6.05], another measure of dynamism, was positively associated with EMR adoption. Physicians practicing in areas with a malpractice crisis, OR = 0.82, 95% CI [0.71, 0.94], representing environmental complexity, had lower EMR adoption rates. PRACTICE IMPLICATIONS: Understanding how market factors relate to practice-based physicians' EMR adoption can assist policymakers to better target limited resources as they work to realize the national goal of universal EMR adoption and meaningful use.

Hospital computerized provider order entry adoption and quality: An examination of the United States.

BACKGROUND: There is increasing national interest in advancing health information technology use in hospitals, but there is little research about the impact on quality in a nationally representative sample. PURPOSES: The purpose of this study was to investigate the relationship between hospital health information technology adoption and quality. Specifically, we examined the relationship between hospital computerized provider order entry (CPOE) and quality. METHODOLOGY: We used a retrospective cross-sectional approach with multiple regression to examine the relationship between hospital CPOE adoption and 10 quality measures from the Hospital Quality Alliance. We used control variables and a propensity score approach to control for confounding factors. FINDINGS: Hospital CPOE adoption is positively and significantly associated with five of the quality measures. A significant negative relationship exists between hospital CPOE adoption and another quality measure. When we controlled for confounding factors using the propensity score approach, the significant relationships remain. PRACTICE IMPLICATIONS: Strategic adoption of health information technology applications in hospitals along with careful and inclusive implementation of such systems is needed for optimal performance. Universal gains in quality are not guaranteed with CPOE adoption.

The distribution of physicians workforce in Louisiana: results from a cross-sectional study.

For the past two decades, Louisiana's population health rankings as reported by the United Health Foundation have been among the lowest in the nation. In addition, the 2009 Commonwealth State Scorecards Report ranked the Louisiana health system performance, in terms of health outcomes, among the poorest in the nation. One reason for this disparity could be attributed to shortages of physicians and other healthcare resources in the state. These shortages were exacerbated by the damage from Hurricanes Katrina and Rita in 2005 to hospitals and physicians' practices in New Orleans and throughout the state. This descriptive cross-sectional study focused on the geographical dimension of access and on one of its critical determinants: the availability of physicians. The objective behind this study was to offer a better understanding of the determinants of geographical imbalances in the distribution of physicians in the state of Louisiana. This study is part one of a three-part series that examines the association between total physician supply, primary care, and specialty care supply on mortality amenable to healthcare (MAHC).

Medicaid Expansion Reduced Uncompensated Care Costs At Louisiana Hospitals; May Be A Model For Other States.

We examined changes in hospital uncompensated care costs in the context of Louisiana's Medicaid expansion. Louisiana remains the only state in the Deep South to have expanded Medicaid under the Affordable Care Act and can serve as a model for states that have not adopted expansion, many of which are located in the South census region. We found that Medicaid expansion was associated with a 33 percent reduction in the share of total operating expenses attributable to uncompensated care costs for general medical and surgical hospitals in Louisiana in the first three years after expansion. Reductions varied by hospital type, with larger effects found for rural and public hospitals versus urban and for-profit or private nonprofit hospitals. As hospital operating expenses consistently increased during the sample period, our results imply that hospitals in Louisiana are treating fewer patients for whom no reimbursement was provided since the state expanded Medicaid.

Effects of Early Dual-Eligible Special Needs Plans on Health Expenditure.

OBJECTIVE: To examine the effects of the penetration of dual-eligible special needs plans (D-SNPs) on health care spending. DATA SOURCES/STUDY SETTING: Secondary state-level panel data from Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011. STUDY DESIGN: A difference-in-difference strategy that adjusts for dual-eligibles' demographic and socioeconomic characteristics, state health resources, beneficiaries' health risk factors, Medicare/Medicaid enrollment, and state- and year-fixed effects. DATA COLLECTION/EXTRACTION METHODS: Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee-for-service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System. PRINCIPAL FINDINGS: Results indicate that D-SNPs penetration was associated with reduced Medicare spending per dual-eligible beneficiary. Specifically, a 1 percent increase in D-SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D-SNPs penetration and Medicaid or total spending. CONCLUSION: Involving Medicaid services in D-SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual-eligible beneficiaries. Starting from 2013, D-SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D-SNPs on health care spending. More research is needed to examine the impact of D-SNPs on dual-eligible spending.

Assessing the performance of freestanding hospitals.

Freestanding hospitals are becoming less common as more hospitals are joining or establishing relationships with multihospital systems. These associations are driven by factors, such as unrelenting competition in local markets, aging physical plants, increasing labor costs, and higher physician fees, that place a high demand on financial assets. Despite these factors, many freestanding hospitals continue to do well financially, showing increases in total profit margins and total cash flow margins. This article examines which market, management, financial, and mission factors are associated with freestanding hospitals with consistently positive cash flows, relative to those without consistently positive cash flows. The study sample consisted of freestanding, nonfederal, short-term, acute care general hospitals with more than 50 beds and three years of annual cash flow data. Data were taken from the annual surveys of the American Hospital Association, the cost reports of the Centers for Medicare and Medicaid Services, and the Area Resource File of the Health Resources and Services Administration. The data were analyzed using logistic regression to identify those factors associated with a consistently positive cash flow. Freestanding hospitals with positive cash flows were found to have a greater market share and to be located in markets with a higher number of physicians and fewer acute care beds; to have fewer unoccupied beds, higher net revenues, greater liquidity, and less debt on hand; and to treat fewer Medicare patients than those without a positive cash flow. The findings suggest that these hospitals are located in resource-rich environments and that they have strong management teams.

County Smoke-Free Laws and Asthma Discharges: Evidence from 17 US States.

BACKGROUND: Although approximately 82 percent of the US population was covered by some form of law that restricted smoking in public establishments as of 2014, most research examining the relationship between smoke-free laws and health has been focused at the state level. PURPOSE: To examine the effect of county workplace smoke-free laws over and above the effect of other (restaurant or bar) smoke-free laws on adult asthma. METHODS: The study estimated the effect of rates of adult asthma discharges before and after the implementation of county nonhospitality workplace smoke-free laws and county restaurant and bar smoke-free laws. Data were from 2002 to 2009, and all analyses were performed in 2011 through 2013. RESULTS: A statistically significant relationship (-5.43, p < .05) was found between county restaurant or bar smoke-free laws and reductions in working age adult asthma discharges. There was no statistically significant effect of nonhospitality workplace smoke-free laws over and above the effect of county restaurant or bar laws. CONCLUSIONS: This study suggests that further gains in preventable asthma-related hospitalizations in the US are more likely to be made by focusing on smoke-free laws in bars or restaurants rather than in nonhospitality workplaces.