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Abstract

Amid state and federal initiatives to bolster healthcare practitioners’ religious freedom, the impact of hospital religious affiliations on health outcomes has become a pertinent question. Despite the significance of this issue, there appears to be a lack of research examining the potential differences in health outcomes between religiously affiliated and secular hospitals. Addressing this gap, our exploratory study utilizes health outcome data from 291 California hospitals from 2016 to 2020. We evaluate health outcomes across a spectrum of interventions and events, accounting for variables such as the category of health condition (eg, cardiovascular, gastrointestinal, musculoskeletal, pulmonary, pancreatic). We find evidence that hospital funding partially moderates the relationship between religious hospitals and health outcomes. While there are no differences in health outcomes between religious and secular hospitals at the lowest levels of revenue, as revenue increases, religious hospitals have more adverse health outcomes than their secular hospital counterparts. These results highlight the need for further investigation into how institutional priorities and resource allocation in religious hospitals may affect patient care, particularly as hospital revenue increases.

Keywords

hospitals healthcare health outcomes religious hospitals secular hospitals

Highlights

● Hospital funding partially moderates the relationship between religious hospitals and health outcomes.

● At higher revenue levels, religious hospitals have more adverse health outcomes than their secular hospital counterparts.

Introduction

In the United States, nearly 20% of hospitals have a religious affiliation.¹ Over 800 million people per year receive healthcare at a Catholic hospital in the United States.² Indeed, the 10 largest Catholic healthcare systems collectively own approximately 50% of all short-term acute care hospitals.³ In the current political environment, one in which there is an increasing number of state and federal initiatives to bolster the religious freedoms of healthcare practitioners, the impact of religious affiliations on health outcomes is an increasing area of concern, particularly when the ethical and religious directives of religious organizations are in conflict with standard medical practice.^4
-7

Existing health outcomes research provides valuable insights into various factors that influence patient well-being within healthcare settings. Predictors such as hospital size,⁸ patient demographics,^9,10 and quality of care¹¹ have been extensively studied. Likewise, research has explored patient experiences in religious hospitals as opposed to secular hospitals,^1,12 and provision of care as it relates to religious affiliation.^13
-15 However, the relationship between hospital religious affiliation and health outcomes remains relatively unexplored.

Hospital religious affiliation is rarely explored in the research. When it is, virtually all research explores service provision and patient satisfaction rather than health outcomes.^1,12
-15 There may be higher patient satisfaction with religious hospitals, despite minimal quality of care differences.¹⁶ Sociopolitical events may also impact patients, particularly women, who express concerns about receiving certain kinds care at religious hospitals (eg, obstetrics and gynecological).^17,18 Regarding the direct relationship between religious hospitals and patient outcomes, we were able to identify only one article that examines this.

In their research, Garrido et al¹ explore infant mortality differences across Catholic and non-religious hospitals, finding no differences between Catholic and non-religious hospitals. However, 2 notable issues arise that warrant further investigation. First, they do not account for potentially massive funding differences between hospitals. Religious hospitals engage in more community outreach events, which may attract more donors and funding than nonreligious hospitals.^19,20 Church-owned hospitals have also been found to be more efficient, which could also contribute to their ability to attract funding.²¹ Second, Garrido et al look exclusively at infant mortality outcomes. They hypothesize that Catholic hospitals are more likely to devote energies to helping infants, given explicit Catholic doctrines from John Paul II. However, there is little reason to suspect that nonreligious hospitals would be more likely to withhold care for infants. Rather, it may be that Catholic hospitals devote more energies to infant care, but only compared to the energies they provide to other areas of care (eg, cardiac, neurological). Secular hospitals, however, may have a more equitable distribution of resources, as they need not adopt specific prescribed moral approaches to medicine.

There is, however, reason to suspect that the religious affiliation of a hospital may be directly related to health outcomes. Due to codified religious doctrines, religious hospitals may choose to withhold certain end of life care, or refuse certain medical procedures, per religious objections.^22
-29 For example, some religious hospitals may restrict family planning services, sterilizations, and necessary medical and surgical abortions.^22,23 This is especially true in Catholic and Jewish traditions, which often have the most conservative positions on end of life treatment.¹ In fact, accessibility of contraceptives and access to reproductive health care has been found to be limited in religious hospitals.^24
-29 These restrictions can result in significant gaps in care, potentially leading to poorer health outcomes for affected patients.^30,31 Additionally, the necessity for patients to seek alternative providers for certain services can cause delays in receiving timely care, further exacerbating health risks. This leads us to our first hypothesis, below:

H1: Religious affiliation is directly related to health outcomes

However, the argument that religious affiliation impacts the distribution of finite resources is strongest when the resources are especially limited. Hospital administrators operating with an abundance of resources may distribute resources more equitably, as there is less overall strain on the system, and thus less need to prioritize certain areas of treatment in order to obtain adequate care. Financially robust hospitals, regardless of religious affiliation, can afford newer technologies and can attract the most skilled professionals, both of which likely positively improve health outcomes.^32
-35 Hospitals operating under austerity measures are likely to allocate funds differently than hospitals with more funding. For example, religious hospitals, compared to secular hospitals, may allocate more funding to labor and delivery and neonatal intensive care units (NICU), consistent with religious doctrines prioritizing infants’ lives. Indeed, Catholic-affiliated hospitals have been found to have comparatively more infants in NICUs.³⁶ In turn, this would result in comparatively less funding for certain surgeries or advanced end-of-life care that may be perceived as “unnaturally” extending end of life. Outside of direct care, religious hospitals may allocate resources differently too.^37
-39 For example, religious hospitals were more likely to make financial contributions to the local community compared to other nonprofits and for-profits.¹⁹ Thus, we suggest that religiously affiliated hospitals may have different health outcomes than nonreligious hospitals, in part, due to the ways they allocate fundings. We suggest that our data, which focus on hospital areas outside of infants and children, may show the greatest disparities between religious and nonreligious hospitals when it comes to funding. If, indeed, funding moderates the relationship between religious affiliation and health outcomes, we would expect different relationship between hospital religious affiliation and health outcomes to matter more under low levels of funding than high levels of funding. Given this, we include our second hypothesis below:

H2: The relationship between religious affiliation and health outcomes is moderated by hospital funding

Addressing this gap, our exploratory study utilizes the California Hospital Performance Ratings dataset, which provides risk-adjusted performance ratings on various surgical and non-surgical interventions (eg, coronary artery bypass graft, acute myocardial infarction, percutaneous coronary intervention) across 291 hospitals from 2016 to 2020.

Methods

Sample

This study is a descriptive analysis of multiple datasets about California hospitals. We utilize the California Hospital Performance Ratings dataset.⁴⁰ This publicly available dataset includes 333 hospitals in the state of California. It includes health outcomes for each hospital for the years 2016 to 2021, totaling 21 277 observations. We then merged into the dataset the financial information for each hospital, using the publicly available Hospital Annual Utilization Reports.⁴¹ We drop hospitals that are not in both datasets or have missing data, for a total sample of 291 hospitals and 10 089 observations. Otherwise, all hospitals in the dataset are included. We follow the CHEERS EQUATOR guidelines for this study.⁴²

Measures

Our independent variable is religious affiliation. Each of the hospitals was coded as either having a religious affiliation or not based on whether they reported their governing body was a church or not (0 = secular, 1 = religious). We also include gross revenue and total debt, which we gather directly from Hospital Annual Utilization Reports.⁴¹ Hospitals report their total operating revenue as well as total liabilities. We create a variable to identify the body system that is targeted/impacted (1 = cardiovascular, 2 = GI, 3 = musculoskeletal, 4 = pancreas, 5 = pulmonary) to capture both emergent and non-emergent conditions with possible overlapping pathology within body systems. We also create variables to identify whether a performance measure is assessing a surgery or not (0 = non-surgical, 1 = surgical) and whether the intervention was elective or not (0 = non-elective, 1 = elective). We also control for the number of pediatric and general cardiologists, pediatric and general surgeons, and pediatric medicine and general preventative medicine specialists. Finally, we use variables from the California Hospital Performance Ratings dataset⁴⁰ to identify the number of adverse health events for a given outcome as well as the total number of medical cases. Adverse health events are defined as the number of outcomes that correspond with each performance measures (eg, acute stroke, carotid endarterectomy, GI hemorrhage, heart failure, hip fracture, pneumonia, postoperative sepsis) in the California Hospital Performance Ratings dataset.⁴¹

Analyses

We begin by producing descriptive statistics for all included variables (Table 1). We then run an ordinary least squares (OLS) regression to identify the main effects and to model the interaction between religious affiliation and funding.

Table 1.

Descriptive Statistics.

Variable	Obs	Mean	Std. dev.	Min	Max
Number of adverse cases	10 107	7.48	11.88	0	167
Religious affiliation	10 107	0.12	0.32	0	1
Revenue (millions)	10 107	434	542	0.53	4610
Surgery	10 107	0.10	0.30	0	1
Intervention type	10 107			1	5
Cardiovascular	10 107	0.66	0.47	1	1
Gastrointestinal	10 107	0.10	0.31	2	2
Musculoskeletal	10 107	0.10	0.30	3	3
Pancreatic	10 107	0.028	0.17	4	4
Pulmonary	10 107	0.11	0.31	5	5
Elective	10 107	0.01	0.08	0	1
Pediatric cardiologist	10 107	0.72	3.13	0	44
General cardiologist	10 107	3.69	11.2	0	126
Pediatric surgeon	10 107	0.28	1.22	0	9
General surgeon	10 107	4.04	10.32	0	93
Pediatric medicine	10 107	8/93	26.51	0	385
General preventative medicine	10 107	0.25	2.34	0	32
Debt (in millions)	10 107	260	2338	0.12	5920
Number of cases	10 107	158.59	183.14	0	1890

Results

Our OLS regressions suggest a main effect of religious affiliation such that religiously affiliated hospitals tend to have more negative adverse health events. This supports hypothesis 1. Additionally, there is a significant moderating impact of gross revenue which interacts with religious affiliation (P < .001; Figure 1). This provides support for hypothesis 2. At lower levels of revenue, there do not appear to be any differences in health outcomes between secular and religious hospitals (Table 2). However, we find that religiously affiliated hospitals have more adverse health outcomes than secular hospitals. Additionally, we see that gross revenue negatively impacts health outcomes (β = .15, P < .01), though minimally. However, the impact of gross revenue is greater for religiously affiliated hospitals than non-religiously affiliated hospitals (Figure 2). We also find that, net of other factors, gastrointestinal (β = −.15, P < .001), musculoskeletal (β = −.13, P < .001), and pulmonary-related issues (β = −.13, P < .001) have fewer adverse health outcomes than cardiovascular-related issues. Additionally, elective interventions have fewer adverse health outcomes than non-elective interventions (β = −.04, P < .001). Finally, we find that the number of general cardiologists (β = −.05, P < .001) and pediatric surgeons (β = −.03, P < .01) both are related to fewer adverse health outcomes.

Figure 1.

Marginal effects of religious affiliation and revenue interaction.

Table 2.

OLS Estimates of Support on Sentiments (Standardized Coefficients).

Variable	Number of adverse cases
Religious affiliation	−0.04** (0.48)
Revenue (millions)	0.15** (27 000)
Religious × revenue	0.10*** (1020)
Surgery	−0.13*** (0.35)
Intervention type
Gastrointestinal	−0.15*** (0.28)
Musculoskeletal	−0.13*** (0.29)
Pancreatic	−0.00 (0.58)
Pulmonary	−0.13*** (0.27)
Elective	−0.04*** (1.04)
Pediatric cardiologist	−0.02 (0.05)
General cardiologist	−0.05*** (0.01)
Pediatric surgeon	−0.03** (0.10)
General surgeon	0.02 (0.01)
Pediatric medicine	0.01 (0.01)
General preventative medicine	0.12** (0.04)
Debt (in millions)	0.01 (21 400)
Number of cases	0.58*** (0.00)
Constant	2.29*** (0.15)
N	10 107
R-sq	.51

Note. Standard errors in parentheses.

P < .05, **P < .01, ***P < .001; Cardiovascular used as control group.

Figure 2.

Marginal effects of gross revenue by religiosity.

Discussions

We find strong evidence that religious affiliation does, indeed, impact health outcomes. However, these results are moderated by hospital funding. We suggest that this work expands on the existing literature by (a) looking at the relationship between hospital religious affiliation and health outcomes, (b) looking at multiple health outcomes (rather than solely infant mortality), and (c) accounting for the role of funding.

Within our datasets, we find support for hypothesis 1, though the relationship between a hospital’s religious affiliation and patient health outcomes is nonlinear based on hospital revenue, supporting hypothesis 2. At lower levels of revenue, religious hospitals and secular hospitals have similar health outcomes. At higher levels of revenue, religious hospitals have significantly more adverse health outcomes compared to secular hospitals, net of other factors, including total number of cases. We suggest that this notable finding may be due to the ideological orientation of religious hospitals.

We suggest that religious hospitals often have a dual mission: providing medical care and fulfilling religious objectives. This dual focus can lead to theologically-driven decisions about resource allocation, some of which may inadvertently compromise certain aspects of patient care (eg, cardiovascular outcomes in adults).^23,43 Some evidence suggests religious healthcare nonprofits differ in their resource allocation, ultimately resulting in differing rates of laboratory testing and hospital resource utilization.⁴⁴ Core values, like Catholic hospitals’ values of stewardship, impact operational approaches (eg, distribution of human and financial resources).⁴⁵ For religious hospitals, significant funds may be allocated for pastoral care services, religious programing, and community outreach programs.⁴⁶ While these services are broadly beneficial,⁴⁷ they also divert resources away from direct medical care, staffing, and investment in technological infrastructure. Divestments are exacerbated as religious non-profit hospitals face pressures from both the federal and state levels to engage in more charitable work to justify tax exempt statuses.²⁸ For underfunded religious hospitals—ones that may also have to fund chaplaincy programs, prayer rooms, religious counseling and more—this means less money for the acquisition of advanced medical equipment, and less money for renovating outdated facilities. Medical technologies and infrastructure in particular are a major area of cost for hospitals,^48
-51 and divestment could disproportionately impact these areas. Other cost cutting measures include cutting the number of acute care beds⁵² and reducing the number of staff.⁵³ As a result, underfunded religious hospitals may struggle to keep pace with technological advancements, ones that improve diagnostic accuracy and treatment efficacy, that secular hospitals with comparable funding may be able to invest in.

Regarding patient demographics, while religious individuals may have a preference for religious hospitals, religious affiliation at the individual level has mixed results regarding health outcomes.⁵⁴ While some find that religious affiliation predicts higher morbidity rates,⁵⁵ others find that there is either lower rates⁵⁶ or no relation.⁵⁴ While it might be true that religious individuals may prefer to seek out hospitals that share the same religious affiliation as they do, it is not expected that any religious or nonreligious group will disproportionately experience negative health outcomes across the entire state. There is no evidence to suggest that religious individuals experiencing cardiac arrest, stroke, or other medical emergencies actively seek out religious hospitals either.¹ Given this, we argue that selection bias driven by religious affiliation is not confounding our results.

Future Directions and Limitations

One limitation is the relative lack of comprehensive data at the patient-level. These data did not include patient demographics, comorbidities, and the specific nature of the health services provided. This incomplete data may skew results and make it challenging to draw definitive conclusions about the true drivers of health outcomes. This is also evident in the relatively low variance in health outcomes are captured by the current dataset, as represented in the low coefficient of determination levels. However, we also note the statewide scope and aggregated outcome measures reduce the likelihood that demographic imbalances are systematically driving the results. Because outcomes are aggregated at the hospital level, individual demographic variation is likely to be randomly distributed across the nearly 300 hospitals in the sample. While it remains possible that certain demographic patterns could cluster by hospital type, we don’t find evidence to suggest systematic alignment between those patterns, religious affiliation, and adverse health outcomes. Therefore, we suggest the observed relationships should be interpreted as reflecting structural and institutional patterns. Ultimately, we suggest that future researchers should explore health outcomes using both hospital data (eg, religious affiliation, staffing, funding) and patient data (eg, demographics, health conditions).

Additionally, we do not explore the extent to which religious hospitals require staff, including administrators, doctors, and nurses, to be religious. This limits our ability to identify how religious affiliation among staff might influence hospital operations, care delivery, and patient outcomes. If religious hospitals prioritize hiring staff who share their faith, for example, this could impact various aspects of hospital performance, including staff cohesion, patient-staff interactions, and adherence to religiously-influenced care practices. Additionally, some hospitals may be religious in name and affiliation only, but do not adhere to strict theological or doctrinal expectations.^23,43 Thus, our binary coding of religious affiliation may not accurately identify the continuum of religious practices a hospital engages in. Future researchers should investigate the hiring practices of religious hospitals to determine whether religious affiliation among staff correlates with differences in health outcomes, resource allocation, and overall hospital performance. Researchers should also directly measure how religious hospitals allocate resources to religious programing (eg, pastoral care, religious services), as we suggest they likely do in this paper. Understanding these dynamics could provide valuable insights into how the integration of faith and professional roles influences the effectiveness and efficiency of religious hospitals.

Finally, we note that our measure of gross revenue may not accurately capture the full picture of resource availability and allocation. Other financial aspects, such as endowment funds and charitable donations, could significantly influence a hospital’s ability to invest in medical care and technology, and these were not accounted for. We encourage future researchers to expand on these findings and utilize data that more comprehensively assesses the finances of hospitals, and how these finances may moderate the relationship between religious affiliation and patient health outcomes. Some of these financial aspects may also be partially captured by identifying metropolitan, urban, or rural locations of hospitals, which was also absent in our data. The location of hospitals may also impact the market competition that hospitals are embedded within, which may also impact the resource allocation and healthcare administration decisions hospital administration make.

Conclusion

This study provides initial evidence that hospital religious affiliation may be associated with differences in patient health outcomes, and that these differences appear to vary by hospital funding levels. While the dual mission of religious hospitals - to provide both spiritual care and medical care—may shape how resources are allocated, further research is needed to confirm the extent to which these priorities impact clinical outcomes. Our findings offer preliminary support that high-revenue religious hospitals have a greater number of adverse health outcomes, though the mechanisms behind this relationship are not directly tested and remain unclear. This study contributes to the existing literature by exploring how resource allocation—conditioned by ideology—impacts health outcomes. We encourage future researchers to incorporate patient-level data, examine the degree of religious integration within hospitals, and explore additional financial indicators to better understand the relationships between institutional affiliation and healthcare outcomes.

Supplemental Material

sj-pdf-1-inq-10.1177_00469580251350813 – Supplemental material for Religious Hospitals and Poorer Health Outcomes: A Case Study Using Hospital Performance Ratings

Supplemental material, sj-pdf-1-inq-10.1177_00469580251350813 for Religious Hospitals and Poorer Health Outcomes: A Case Study Using Hospital Performance Ratings by Justin Huft and Katrina Guardino in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

ORCID iD

Justin Huft

Ethical Considerations

This work did not require IRB review. All data is publicly available and does not directly involve human subjects.

Author Contributions

Both authors worked on all parts of the manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data uses publicly available data sources.

Supplemental Material

Supplemental material for this article is available online.

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Kiser

Hogue

Religion, a social determinant of mortality? A 10-year follow-up of the Health and Retirement Study. PLoS One. 2017;12(12):e0189134. doi:10.1371/journal.pone.0189134

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