Defining Incidental Versus Non-incidental COVID-19 Hospitalizations

Dhimitri A Nikolla; Jonathan J Oskvarek; Mark S Zocchi; Nishad A Rahman; Andrew Leubitz; Ali Moghtaderi; Bernard S Black; Jesse M Pines

doi:10.7759/cureus.56546

Defining Incidental Versus Non-incidental COVID-19 Hospitalizations

Cureus. 2024 Mar 20;16(3):e56546. doi: 10.7759/cureus.56546. eCollection 2024 Mar.

Authors

Dhimitri A Nikolla^{1

2

3}, Jonathan J Oskvarek^{4

3}, Mark S Zocchi^{5

3}, Nishad A Rahman^{6

3}, Andrew Leubitz^{7

3}, Ali Moghtaderi⁸, Bernard S Black⁹, Jesse M Pines^{10

3}

Affiliations

¹ Department of Internal Medicine / Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA.
² Department of Emergency Medicine, Allegheny Health Network, Erie, USA.
³ US Acute Care Solutions (USACS) Research Group, US Acute Care Solutions, Canton, USA.
⁴ Department of Emergency Medicine, Summa Health System, Akron, USA.
⁵ Heller School for Social Policy and Management, Brandeis University, Waltham, USA.
⁶ Department of Emergency Medicine, LifeBridge Health - Sinai Hospital, Baltimore, USA.
⁷ Department of Emergency Medicine, Adventist HealthCare - Shady Grove Medical Center, Rockville, USA.
⁸ Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
⁹ Pritzker School of Law and Kellogg School of Management, Northwestern University, Chicago, USA.
¹⁰ Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, USA.

Abstract

Background Rates of COVID-19 hospitalization are an important measure of the health system burden of severe COVID-19 disease and have been closely followed throughout the pandemic. The highly transmittable, but often less severe, Omicron COVID-19 variant has led to an increase in hospitalizations with incidental COVID-19 diagnoses where COVID-19 is not the primary reason for admission. There is a strong public health need for a measure that is implementable at low cost with standard electronic health record (EHR) datasets that can separate these incidental hospitalizations from non-incidental hospitalizations where COVID-19 is the primary cause or an important contributor. Two crude metrics are in common use. The first uses in-hospital administration of dexamethasone as a marker of non-incidental COVID-19 hospitalizations. The second, used by the United States (US) CDC, relies on a limited set of COVID-19-related diagnoses (i.e., respiratory failure, pneumonia). Both measures likely undercount non-incidental COVID-19 hospitalizations. We therefore developed an improved EHR-based measure that is better able to capture the full range of COVID-19 hospitalizations. Methods We conducted a retrospective study of ED visit data from a national emergency medicine group from April 2020 to August 2023. We assessed the CDC approach, the dexamethasone-based measure, and alternative approaches that rely on co-diagnoses likely to be related to COVID-19, to determine the proportion of non-incidental COVID-19 hospitalizations. Results Of the 153,325 patients diagnosed with COVID-19 at 112 general EDs in 17 US states, and admitted or transferred, our preferred measure classified 108,243 (70.6%) as non-incidental, compared to 71,066 (46.3%) using the dexamethasone measure and 77,399 (50.5%) using the CDC measure. Conclusions Identifying non-incidental COVID-19 hospitalizations using ED administration of dexamethasone or the CDC measure provides substantially lower estimates than our preferred measure.

Keywords: coronavirus disease 2019; dexamethasone; emergency medicine; health policy; hospital admission; internal medicine; pandemic; public health.