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

Bravata DM, Myers LJ, Perkins AJ, Keyhani S, Zhang Y, Zillich AJ, Dysangco A, Lindsey R, Sharmitha D, Myers J, Austin C, Sexson A, Arling G. Heterogeneity in COVID-19 patient volume, characteristics and outcomes across US Department of Veterans Affairs facilities: an observational cohort study. BMJ open. 2021 Mar 8; 11(3):e044646.

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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.

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