Are COVID-19 Mortality Rates in the US Improving Over Time?
BACKGROUND AND PURPOSE:
Asch et al. (JAMA Internal Medicine, 2020) examined the change in COVID-19 hospital mortality rates over the first 6 months of the pandemic
Cohort study (January 1, 2020 to June 30, 2020)
Adults admitted to a US hospital with COVID-19
Size | Number of ICU beds | Academic and profit status | Hospital setting and regional characteristics | COVID-19 case burden
Hospital’s risk-standardized event rate (RSER) of 30-day in-hospital mortality or referral to hospice, with adjustment for patient-level characteristics
The authors examined whether hospital characteristics were associated with RSERs or their change over time
Subset analysis of patients admitted to hospitals that treated ≥10 COVID-19 patients
38,517 adults | 955 hospitals
Mean (SD) age 70.2 (15.5) years | 51.0% women
Mean (SD) hospital-level RSER: 11.8% (2.5%)
Mean RSER in the worst-performing quintile of hospitals: 15.65%
Mean RSER in the best-performing quintile of hospitals: 9.06%
Absolute difference 6.59 percentage points (95% CI, 6.38% to 6.80%); P < 0.001
Mean RSERs improved in all but 1 of the 398 hospitals that treated ≥10 COVID-19 patients
94% (376 hospitals) improved by at least 25%
The overall mean (SD) RSER declined from 16.6% (4.0%) to 9.3% (2.1%)
Absolute differences in rates of mortality or referral to hospice between the worst- and best-performing quintiles of hospitals decreased over time
January 1 to April 30: 10.54 percentage points (95% CI, 10.03% to 11.05%); P < 0.001
May 1 to June 30: 5.59 percentage points (95% CI, 5.33% to 5.86%); P <0 .001
Higher county-level COVID-19 case rates were associated with worse RSERs
Case rate declines were associated with improvement in RSERs
Hospital mortality rates due to COVID-19 declined “sharply” during the first six months of the pandemic
94% of hospitals had a relative mortality reduction of >25%
Accrued clinical experience and use of medications (e.g., dexamethasone) could account for some of this improvement
Mortality rate declines were associated with decreased COVID-19 case loads at the county level
The authors state
This study revealed that outcomes for patients with COVID-19 rely not only on individual-level risk factors, but also on the hospital where care is received
The association between high community COVID-19 case loads and both worse RSERs and greater improvement in RSERs suggests hospitals do worse when they are burdened with cases and is consistent with imperatives to flatten the curve
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