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Hospital-Level Variation in Death for Critically Ill Patients with COVID-19
Matthew M Churpek1, Shruti Gupta2, Alexandra B Spicer3
1University of Wisconsin Madison, 5228, Medicine; Division of Pulmonary and Critical Care, Madison, Wisconsin, United States; mchurpek@medicine.wisc.edu.
Insights
Hospital mortality variation in critically ill coronavirus disease 2019 (COVID-19) patients is largely explained by hospital-level socioeconomic status, strain, and acute physiology. Individual patient factors primarily drive mortality risk.
Area of Science:
- Critical Care Medicine
- Epidemiology
- Health Services Research
Background:
- Hospital mortality rates for coronavirus disease 2019 (COVID-19) exhibit significant variation.
- The specific factors contributing to this interhospital mortality difference remain largely undetermined.
Purpose of the Study:
- To identify patient-level and hospital-level factors that explain mortality variability in critically ill adults with COVID-19.
- To quantify the contribution of different domains to individual patient mortality risk.
Main Methods:
- A multicenter cohort study involving 4,019 critically ill adults with COVID-19 across 70 US hospitals (March-June 2020).
- Analysis included mixed-effects logistic regression to assess interhospital variation and a gradient boosted machine algorithm for individual mortality prediction.
- Key variables examined encompassed acute physiology, demographics, comorbidities, socioeconomic status, hospital strain, quality, and treatments.
Main Results:
- Overall 28-day mortality was 38% (1537/4019), with substantial hospital-level variation (0-82%).
- Interhospital variation in mortality significantly decreased after adjusting for patient and hospital factors, particularly acute physiology, socioeconomic status, and strain.
- For individual patients, acute physiology (49%) was the largest contributor to mortality risk, followed by demographics/comorbidities (20%) and socioeconomic status (12%).
Conclusions:
- Considerable interhospital variation exists in COVID-19 mortality, primarily explained by hospital-level socioeconomic status, strain, and acute physiologic factors.
- Individual patient mortality is predominantly influenced by patient-level characteristics, including acute physiology and demographics.
- Understanding these factors is crucial for addressing disparities and improving outcomes in critically ill COVID-19 patients.
Rationale:
Variation in hospital mortality has been described for coronavirus disease 2019 (COVID-19), but the factors that explain these differences remain unclear.
Objective:
Our objective was to utilize a large, nationally representative dataset of critically ill adults with COVID-19 to determine which factors explain mortality variability.
Methods:
In this multicenter cohort study, we examined adults hospitalized in intensive care units with COVID-19 at 70 United States hospitals between March and June 2020. The primary outcome was 28-day mortality. We examined patient-level and hospital-level variables. Mixed-effects logistic regression was used to identify factors associated with interhospital variation. The median odds ratio (OR) was calculated to compare outcomes in higher- vs. lower-mortality hospitals. A gradient boosted machine algorithm was developed for individual-level mortality models.
Measurements And Main Results:
A total of 4,019 patients were included, 1537 (38%) of whom died by 28 days. Mortality varied considerably across hospitals (0-82%). After adjustment for patient- and hospital-level domains, interhospital variation was attenuated (OR decline from 2.06 [95% CI, 1.73-2.37] to 1.22 [95% CI, 1.00-1.38]), with the greatest changes occurring with adjustment for acute physiology, socioeconomic status, and strain. For individual patients, the relative contribution of each domain to mortality risk was: acute physiology (49%), demographics and comorbidities (20%), socioeconomic status (12%), strain (9%), hospital quality (8%), and treatments (3%).
Conclusion:
There is considerable interhospital variation in mortality for critically ill patients with COVID-19, which is mostly explained by hospital-level socioeconomic status, strain, and acute physiologic differences. Individual mortality is driven mostly by patient-level factors. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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