Hospital Performance, Nursing Resources, and Health Inequities During the COVID-19 Pandemic

Few researchers have examined the organizational features of high-performing and low-performing hospitals for COVID-19 mortality during the pandemic, and how differences in hospital performance contributed to mortality disparities among socially vulnerable patients hospitalized with COVID-19.

Our objectives were (a) to identify high- and low-performing hospitals on COVID-19 inpatient mortality and describe their distinguishing organizational characteristics, including nursing resources, and (b) to assess whether patients admitted to high-performing hospitals differed by social vulnerability level.

This analysis used linked nurse survey, hospital, and claims data for 73,792 hospitalized older adults diagnosed with COVID-19 across 96 New York and Illinois hospitals between January 1, 2020, and December 31, 2020. A robust benchmarking approach was used to identify high- and low-performing hospitals on 30-day inpatient mortality. We computed the cumulative proportion of admissions for patients in the highest and lowest social vulnerability index quartiles to the hospitals ranked by performance.

The average mortality rate in the high-performing hospitals was 16.2% compared to 31.5% in the low-performing hospitals. Compared to low-performing hospitals, high-performing hospitals had more favorable nurse work environments and lower patient-to-nurse ratios. About half the patients in the lowest social vulnerability quartile (least vulnerable) were admitted to hospitals in the top-performing tertile of hospitals compared to 38% of patients in the highest social vulnerability quartile (most vulnerable).

Nursing resources were a central feature of a high-performing hospital for COVID-19 mortality during the early stages of the pandemic. Patients diagnosed with COVID-19 who were admitted from the most socially vulnerable communities were less likely to be admitted to high-performing hospitals. Increasing nursing resources-particularly in hospitals that serve socially vulnerable communities-could be a key strategy for preparing for future public health emergencies and addressing health disparities.