Mortality for Time-Sensitive Conditions at Urban vs Rural Hospitals During the COVID-19 Pandemic

Abstract

Importance: COVID-19 pandemic-related disruptions to the health care system may have resulted in increased mortality for patients with time-sensitive conditions.

Objective: To examine whether in-hospital mortality in hospitalizations not related to COVID-19 (non-COVID-19 stays) for time-sensitive conditions changed during the pandemic and how it varied by hospital urban vs rural location.

Design, setting, and participants: This cohort study was an interrupted time-series analysis to assess in-hospital mortality during the COVID-19 pandemic (March 8, 2020, to December 31, 2021) compared with the prepandemic period (January 1, 2017, to March 7, 2020) overall, by month, and by community COVID-19 transmission level for adult discharges from 3813 US hospitals in the State Inpatient Databases for the Healthcare Cost and Utilization Project.

Exposure: The COVID-19 pandemic.

Main outcomes and measures: The main outcome measure was in-hospital mortality among non-COVID-19 stays for 6 time-sensitive medical conditions: acute myocardial infarction, hip fracture, gastrointestinal hemorrhage, pneumonia, sepsis, and stroke. Entropy weights were used to align patient characteristics in the 2 time periods by age, sex, and comorbidities.

Results: There were 18 601 925 hospitalizations; 50.3% of patients were male, 38.5% were aged 18 to 64 years, 45.0% were aged 65 to 84 years, and 16.4% were 85 years or older for the selected time-sensitive medical conditions from 2017 through 2021. The odds of in-hospital mortality for sepsis increased 27% from the prepandemic to the pandemic periods at urban hospitals (odds ratio [OR], 1.27; 95% CI, 1.25-1.29) and 35% at rural hospitals (OR, 1.35; 95% CI, 1.30-1.40). In-hospital mortality for pneumonia had similar increases at urban (OR, 1.48; 95% CI, 1.42-1.54) and rural (OR, 1.46; 95% CI, 1.36-1.57) hospitals. Increases in mortality for these 2 conditions showed a dose-response association with the community COVID-19 level (low vs high COVID-19 burden) for both rural (sepsis: 22% vs 54%; pneumonia: 30% vs 66%) and urban (sepsis: 16% vs 28%; pneumonia: 34% vs 61%) hospitals. The odds of mortality for acute myocardial infarction increased 9% (OR, 1.09; 95% CI, 1.06-1.12) at urban hospitals and was responsive to the community COVID-19 level. There were significant increases in mortality for hip fracture at rural hospitals (OR, 1.32; 95% CI, 1.14-1.53) and for gastrointestinal hemorrhage at urban hospitals (OR, 1.15; 95% CI, 1.09-1.21). No significant change was found in mortality for stroke overall.

Conclusions and relevance: In this cohort study, in-hospital mortality for time-sensitive conditions increased during the COVID-19 pandemic. Mobilizing strategies tailored to the different needs of urban and rural hospitals may help reduce the likelihood of excess deaths during future public health crises.

Figure 1.. Odds of In-Hospital Mortality Among Non–COVID-19 Stays for Acute Myocardial Infarction (AMI), Sepsis, and Pneumonia During the Pandemic, Overall and by COVID-19 Burden in the Hospital’s Community Compared With Prepandemic Stays

Because not all states had data available in 2021, the results are limited to the 2020 peripandemic period (March 8 to December 31, 2020). OR indicates odds ratio.

Figure 2.. Odds of In-Hospital Mortality Among Non–COVID-19 Stays for Acute Myocardial Infarction (AMI), Sepsis, and Pneumonia in 2020 and 2021, by Month, Compared With Prepandemic Stays

From April to December 2020, the data included 45 states and the District of Columbia; January to March 2021, 27 states; April to June 2021, 26 states; July to September 2021, 20 states; and October to December 2021, 12 states. OR indicates odds ratio.