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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.
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.