Heterogeneity in COVID-19 patient volume, characteristics and outcomes across US Department of Veterans Affairs facilities: an observational cohort study

Abstract

Objective: Studies describe COVID-19 patient characteristics and outcomes across populations, but reports of variation across healthcare facilities are lacking. The objectives were to examine differences in COVID-19 patient volume and mortality across facilities, and understand whether facility variation in mortality was due primarily to differences in patient versus facility characteristics.

Design: Observational cohort study with multilevel mixed effects logistic regression modelling.

Setting: The Veterans Health Administration (VA) is the largest healthcare system in the USA.

Participants: Patients with COVID-19.

Main outcome: All-cause mortality within 45 days after COVID-19 testing (March-May, follow-up through 16 July 2020).

Results: Among 13 510 patients with COVID-19, 3942 (29.2%) were admitted (2266/3942 (57.5%) ward; 1676/3942 (42.5%) intensive care unit (ICU)) and 679/3942 (17.2%) received mechanical ventilation. Marked heterogeneity was observed across facilities in median age (range: 34.3-83.9 years; facility mean: 64.7, SD 7.2 years); patient volume (range: 1-737 at 160 facilities; facility median: 48.5, IQR 14-105.5); hospital admissions (range: 1-286 at 133 facilities; facility median: 11, IQR 1-26.5); ICU caseload (range: 1-85 at 115 facilities; facility median: 4, IQR 0-12); and mechanical ventilation (range: 1-53 at 90 facilities; facility median: 1, IQR 0-5). Heterogeneity was also observed in facility mortality for all patients with COVID-19 (range: 0%-29.7%; facility median: 8.9%, IQR 2.4%-13.7%); inpatients (range: 0%-100%; facility median: 18.0%, IQR 5.6%-28.6%); ICU patients (range: 0%-100%; facility median: 28.6%, IQR 14.3%-50.0%); and mechanical ventilator patients (range: 0%-100%; facility median: 52.7%, IQR 33.3%-80.6%). The majority of variation in facility mortality was attributable to differences in patient characteristics (eg, age).

Conclusions: Marked heterogeneity in COVID-19 patient volume, characteristics and mortality were observed across VA facilities nationwide. Differences in patient characteristics accounted for the majority of explained variation in mortality across sites. Variation in unadjusted COVID-19 mortality across facilities or nations should be considered with caution.

Keywords: COVID-19; adult intensive & critical care; general medicine (see internal medicine).

Figure 1

The figure displays the total number of COVID-19 Veteran patients across US Veterans Health Administration facilities (panel A; n=160 facilities had at least one COVID-19 positive patient), the number of hospital admissions (panel B; n=133 facilities had at least one COVID-19 hospital admission), the number of patients cared for in an intensive care unit (ICU) per facility (panel C; n=115 facilities had at least one ICU admission); and the number of patients with mechanical ventilation (panel D; n=90 facilities had at least one patient on a mechanical ventilator).

Figure 2

The figure displays the differences in the facility all-cause, 45-day mortality rates for COVID-19 patients: panel A includes 160 facilities with at least one patient with COVID-19; panel B includes 133 facilities with at least one COVID-19 inpatient cared for on a general ward or critical care unit; panel C includes 115 facilities with at least one COVID-10 ICU patient; and panel D includes 90 facilities with at least one patient with COVID-19 who received mechanical ventilation.