In a large retrospective cohort study of over 6000 patients with laboratory confirmed COVID-19 during the initial surge in NYC, USA, we found that patients admitted to community hospitals had higher rates of in-hospital mortality than those admitted to teaching hospitals and this difference persisted after multivariable and propensity score adjustments. In addition, patients who were transferred from a community hospital to a teaching hospital had a lower risk of death compared to patients who were cared for exclusively at community hospitals.
New York City is composed of five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island). As of May 2nd, 2020, Queens and Brooklyn were the top two counties in the United States for the total number of COVID-19 patients and number of deaths [2]. Interestingly, these counties, including the Bronx, had a higher per capita death rate due to COVID-19 than Manhattan [3]. There are several reasons to be considered. First, there are higher proportions of racial/ethnic minorities residing in these boroughs as compared to Manhattan. These populations tend to have higher rates of poverty and lower years of completed education, which may lead to the lower overall awareness of preventative measures as well as reduced access to healthcare [3]. The number of beds per 100,000 population was lower in these boroughs, especially Brooklyn (214 beds) and Queens (144 beds) when compared to Manhattan (534 beds) [3]. Third, location of care may contribute to difference in mortality. All these factors could affect higher mortality rates outside of Manhattan and our data suggest the government and hospitals should gather and allocate greater medical resources, especially for community hospitals in the area which has relatively fewer hospital beds per 100,000 population, during the pandemic of COVID-19. A previous study showed the comparison of mortality between NYC hospitals and non-NYC teaching hospitals resulting in higher mortality in the NYC cohort. Patient cohorts were similar except for more racial diversity in NYC patients, and NYC patients appeared to be sicker on admission [5].
Our data shows granular insights. Even after IPTW adjustment or multivariable adjustment for patient age, race/ethnicity, and comorbidities, patients in community hospitals had significantly higher mortality than those in teaching hospitals, which prompts us to consider that the hospital status and setting may play an important role in outcomes during the COVID-19 pandemic. During the first initial surge of COVID-19 during March/April 2020, hospitals attempted to accommodate the increasing number of patients requiring intensive care by expanding ICU beds and medical staff. However, ICU beds at Mount Sinai Queens and Brooklyn remained inadequate to meet the needs of patients admitted to these two hospitals, even though these hospitals doubled the number of ICU beds during the pandemic (from 37 to 79). It is consistent with higher in-hospital mortality rates among patients without ICU stay or intubation and implies that there was a shortage of supply which might have been one of the factors of high mortality rates at community hospitals. Moreover, our findings remained robust even after adjustments including endotracheal intubation, indicating that disease severity at the different hospital locations is unlikely to be the primary reason for the differences in mortality. The overall mismatch between the high number of COVID-19 patients in Brooklyn and Queens and the low number of per capita medical and ICU beds as well as the relative paucity of medical resources in community hospitals, make it difficult for hospitals to rapidly adapt to the evolving nature of the COVID-19 pandemic and hence contribute to the higher mortality rates seen in community hospitals.
A previous study showed that teaching hospitals tended to have the lowest mortality for hospitalized COVID-19 patients [6] and our study demonstrated that patients transferred from community hospitals to teaching hospitals had better survival than those who were treated in community hospitals only. Our data suggests community hospitals should consider transferring patients with COVID-19 to teaching hospitals to avoid excessive death rates especially during the pandemic of COVID-19 which causes an imbalance of patients’ populations and hospital beds.
Our study has important public health and policy implications. Early on during the pandemic, policymakers must quickly assess and determine which county/region will be most affected in terms of case burden and in turn will require more medical resources, based on the characteristics of residencies and hospital beds, especially ICU capacity. This will be crucial for the follow-up phases of the pandemic and our results suggest that more resources should be provided to community hospitals to alleviate the disparities in mortality [7]. However, we did not assess the quality of care provided in each hospital, which can contribute to outcomes. Thus, the multifactorial approach that combines financial support of community hospitals during the pandemic with continuous improvement of quality of team care across the entire care continuum can contribute to an improvement of care in community hospitals. In addition, government policies such as social distancing and stay-at-home orders to decrease the peak number of infected patients need to be continued to avoid a large number of deaths [8].
Our study has several limitations. Our study included data only from a single healthcare system in NYC, hence reducing the generalizability of our findings to other populations and healthcare systems. Despite fully adjusting for available patients’ baseline characteristics such as age, race/ethnicity, comorbidities, and vital signs as well as endotracheal intubation, remaining residual and unmeasured confounding factors including differences of socioeconomic status between each hospital location, could limit our causal interpretation. One of such factors could be the criteria for which patients were deemed suitable for transfer between community hospitals and teaching hospitals because this information was not readily available. Also, the thresholds for admission might be different between teaching hospitals versus community hospitals given the fact that elderly patients were likely to be admitted in community hospitals. The severity of illness progression upon admission must have varied however it was limited to vital signs at admission in the analysis. And finally, the availability of palliative or long-term care at teaching and community hospitals could affect in-hospital mortality, though we did not have access to this information.
In conclusion, patients who were exclusively cared for at community hospitals had higher mortality rates than those admitted to teaching hospitals, suggesting hospital status and settings might contribute to the differences in patients’ outcomes during the COVID-19 pandemic.