Academic Health Centers (AHC) play a key role in the education, research, and care of patients worldwide. While Anglo-Saxon countries are considered "economic engines" for growth [1] innovation generators, and sustainable health system experimenters, this perspective has emerged only recently in Europe and Latin countries. Globally, the AHCs share the common trait of the triple strategic mission (education, research, and care), but they are very heterogeneous organizations, starting from the governance model.

The fragmented and growing literature on AHC focuses on three main aspects [2]. First, the broader line of research concerns the tripartite mission of the AHCs, the challenges they face, and AHCs’ changing role [3,4,5,6]. They are focused on improving research by aligning universities and hospitals’ academic and clinical missions [7]. Integrating the triple mission is their major issue, often hampered by academic silos (i.e., cultural, social, and cognitive boundaries) [8,7]. This research stream highlights the conflicting tensions between universities, healthcare organizations, and businesses [9,10,11,12,13]. In recent years, greater attention has been paid to the development of Academic Science Centers in the Anglo-Saxon world, whose main mission is to innovate and contribute to local growth and competitiveness [13,14,15,16,17,18]. Second, various strategic, governance, and organizational factors affect the integration of the triple mission, particularly between research and assistance. Abundant literature discusses the issues of organizational structures [19,20,21] and governance [22,23], which tend to change under specific policies and budget constraints, also inducing restructuring and mergers [2,24]. The interdependent relationships between universities and hospitals generate a spectrum of different models [25,1]. The three general models between universities and hospitals are the following [26]: (a) full integration of the hospital and the medical faculty into a single organization; (b) health science centers in which hospitals and medical faculty are still separate entities, albeit within the same governance structure; (c) affiliated hospitals in which universities and hospitals are separate entities and collaborate; (d) a fourth common model is a variant of the latter, but the academic component is mainly engaged in research rather than training. They are properly research hospitals. Third, the AHCs are unique due to national and organizational factors [27]. The diversity of education and health models also translates into differences in terms of research. The world of universities and healthcare has often been reformed in recent decades, and the relationships between universities and hospitals have ever-changing relationships [3].

Recently, Ferlie [18], commenting on Edelman et al.’s article [17], calls to explore the theme of the influence of governance and location on research processes, especially in non-English-speaking settings, where studies are still lacking. No previous study has investigated the influence of governance and organizational AHCs configurations on the productivity and scientific impact of AHCs. Our study wants to fill this gap with an exploratory analysis in the Italian setting. This country is an interesting setting for five reasons. First, more and more AHCs are considered economic engines, where research greatly impacts society. Second, in Italy, there are 82 AHCs that cover the whole nation, in metropolitan areas and small cities. Third, AHC heterogeneity is visible in governance and organizational contextual features. They differ in layout, organizational structure, operation scale and scope, and formal relations between universities and hospitals. Indeed, few are hospitals historically managed by the Universities (fully integrated AHC – in Italy, AOU SSN), others are autonomous hospitals that integrate with the School of Medicine (affiliated AHC - in Italy, AOU), while still others carry out prevalent research activity on the teaching mission (research AHC - in Italy, IRCCS). Fourth, in the last two decades, the Italian AHCs have gone through various changes due to reforms in the health sector (Legislative Decree 517/99) and in the university sector (Legislative Decree 240/2010) and have continuously faced integration and financial sustainability and social challenges (e.g., Regional Health Turnaround Plans) [28]. Fifth, AHCs in Italy are under performance scrutiny. [29] compare university and generalist hospitals in 10 Italian regions. Their analysis primarily investigates the mission of care. The authors consider a set of 27 indicators included in the Interregional Performance Evaluation System (IRPES) and in the National Outcome Evaluation Program (NOEP) to evaluate the performance of hospitals from a multidimensional perspective [30]. According to these authors, the academic nature of the hospital does not influence care performance. Some more recent studies evaluate the research mission of the AHCs and examine the productivity and bibliometric impact indicators (i.e., [31,32]).

Our study (i) includes all 51 public Italian AHCs, (ii) identifies their main configurations based on governance and organizational features, and (ii) how they impact scientific productivity, impact, and growth.

The paper is articulated in the following sections. After the introduction, we illustrate the research methodology and main findings. Finally, we discuss the results and implications.