“During the early days of the COVID-19 pandemic, hospitals observed precipitous declines in ED visits and inpatient admissions,” says Amber K. Sabbatini, MD, MPH, FACEP. “There were sudden reductions in the number of patients presenting with emergent conditions, such as heart attacks and strokes. Simultaneously, researchers also documented higher rates of death in the community that could not be attributed directly to COVID-19. These trends raised concerns that patients were delaying care when they were experiencing potentially emergent symptoms. Moreover, clinics abruptly canceled appointments, and in many cases, alternative resources were not widely available to patients. These disruptions in care likely adversely impact patients’ health and outcomes, especially for time-sensitive and emergent conditions. While policymakers and the public were focusing on the mortality of COVID-19 itself, we suspected that many patients who did not have COVID were experiencing worse outcomes and higher rates of mortality. Therefore, research focusing on these indirect effects of the pandemic was necessary.”

For a paper published in the Journal of Hospital Medicine, Dr. Sabbatini and colleagues aimed to examine changes in in-hospital mortality for patients without COVID-19 during the first 10 months of the pandemic (March 4, 2020-December 31, 2020). “We utilized data from the Providence-St. Joseph health system, which included 51 hospitals across six Western states and more than 789,000 hospitalizations, to determine whether surge periods with high COVID-19 cases were associated with greater mortality for patients hospitalized with common emergent conditions,” Dr. Sabbatini explains. “These surge periods were assigned as two 10-week periods that roughly corresponded to highest COVID case counts in the spring and fall of 2020 (and corresponded to the greatest number of COVID-19 hospitalizations in our sample).”

Elevated Mortality Seen for All Conditions

The main takeaway from the study, the researchers note, is that when COVID-19 case counts and hospitalizations increase, in-hospital mortality for patients with other acute and emergent illnesses also increases. Unplanned hospitalizations dropped sharply during Periods 1 (March 4 to May 13, 2020) and 3 (October 20 to December 31, 2020) by 47.5% and 25% compared with baseline, respectively. However, although volume dropped, adjusted in-hospital mortality increased from 2.9% in the pre-pandemic period to 3.5% in Period 1 (20.7% relative increase), returning to baseline in Period 2 (May 14 to October 19, 2020), and rose again to 3.4% in Period 3. Higher mortality was observed for almost all conditions studies during the pandemic surge periods.

“After adjusting for case-mix, we found a 0.5 and 0.6 percentage point increase in in-hospital mortality (~19% relative increase) for patients admitted during both the spring and fall 2020 COVID-19 surge periods, respectively,” Dr. Sabbatini says. “This translates to an increase of five to six deaths for every 1,000 patients hospitalized overall (Table).”

Protocols Needed to Mitigate Spillover Effects

The observed association between COVID-19 case counts and in-hospital mortality suggests that the pandemic has had adverse spillover effects into other patient populations and that morbidity and mortality due to COVID is much higher than metrics would suggest, according to the study team. “This means that not only do hospitals need to figure out how to effectively manage patients with COVID-19, they also need to develop protocols to mitigate these spillover effects and ensure that quality of care does not decline for other patients,” Dr. Sabbatini says.

The researchers concur that future research should not only confirm whether the same increases in mortality are seen in other populations, but also examine the specific modifiable etiologies for the increase in mortality, which would guide interventions to mitigate these impacts. “There is value in examining outcomes other than mortality to better quantify how the pandemic may increase morbidity for patients without COVID-19 who are experiencing urgent and emergent illnesses,” Dr. Sabbatini says. “Subsequent studies should examine the extent to which these findings relate to patient factors (ie, delayed presentation and more severe disease) or systemic factors (reduction in access or changes in quality of care).”