Three newly published studies in Open Forum Infectious Diseases detail COVID-19 deaths in 2020 and 2021, including one describing an increase in US hospital deaths during a community surge, one finding a rise in the risk of dying at home in North Carolina, and one showing a reduced risk of hospital death in New York City in the second pandemic wave.
US hospital deaths amid community surge
In the first study, University of Texas researchers assessed death rates in 416,962 adult COVID-19 patients at 229 US academic and 432 community hospitals in the Vizient Clinical Database before and during a community case surge from September 2020 to March 2021.
The unadjusted proportion of deaths among hospital patients released from the hospital was 9% before and during the surge, spiking to 12% when cases peaked and then declined. Relative to before the surge, the risk-adjusted odds ratio for death during the period of rising cases was 1.14, peaking at 1.37 and then falling to 1.30 as cases declined.
The surge-related increase in hospital deaths was observed in seven of nine geographic areas and was higher in community hospitals than for academic centers. "The similarity of the pattern across settings suggests shared factors contributed to elevated risk," the researchers wrote. "One possible explanation is that limited bed capacity shifted admitting preference to the most severely ill."
They added that the link between community COVID-19 surges and in-hospital deaths could not be explained by differences in demographic, clinical, or hospital characteristics.
"These data support healthcare policies aimed at containing pandemic surges to prevent case overloads for hospitals, public health and public policy efforts to provide supplemental manpower and capacity support to hospitals at risk of surge overload, and standardized hospital surge strategies," the authors concluded.
Hispanic, Black people hardest hit
The second study, by University of North Carolina researchers, entailed examination of state death certificate data on in-home deaths due to COVID-19 or any cause from Mar 1, 2020, to Dec 31, 2021.
Of 22,646 COVID-19 deaths, 1,771 (7.8%) occurred at home. The cumulative risk of dying at home of COVID-19 rose from 3.3 per 100,000 people on Dec 31, 2020, to 13.0 per 100,000 on Dec 31, 2021.
The cumulative rate of at-home COVID-19 death among Hispanic people was 9.9 per 100,000 people, compared with 2.3 per 100,000 among their White peers at the end of 2020 (difference, 7.6 per 100,000). At the end of 2021, COVID-19 home death rates were 19.0 and 11.4 per 100,000 people among Hispanic and White people, respectively (difference, 7.6).
Rates of home deaths were also higher among Black people than among their White counterparts (difference, 5.6 per 100,000) at the end of 2021. While home death rates from any cause rose overall, they were highest among Hispanic people.
"These findings suggest perennial barriers to care prevent those with progressive COVID-19 from accessing medical attention and the need for initiatives that extend healthcare access for those disproportionately impacted by COVID-19 to prevent avoidable death," the researchers wrote.
Role of hospital strain on death rate
In New York City, Columbia University Irving Medical Center researchers analyzed the clinical and demographic data of COVID-19 patients admitted to the hospital during the first wave of the pandemic (March to August 2020) and the second (August 2020 to March 2021).
The 4,631 patients had lower overall and 30-day rates of in-hospital death or release to hospice during the second wave (14% and 11%, respectively) than during the first (22% and 21%, respectively). The reduced death rate during the second wave persisted after adjustment for potential confounders. Adjustment for the volume of COVID-19 hospitalizations, an indicator of health system strain, explained the between-wave difference in death rates.
Risk factors for death in both waves included high viral load, do-not-intubate status, and the need for supplemental oxygen and intensive care.
"This work suggests that increased in-hospital mortality rates observed during the first epidemic wave were partly due to strain on hospital resources," the researchers wrote. "Preparations for future epidemics should prioritize evidence-based patient risks, treatment paradigms, and approaches to augment hospital capacity."
