It has become well-established over the past two years that the COVID-19 pandemic has affected healthcare from almost every angle, including the healthcare of those not suffering from COVID-19.
Thomas Higgins, MD, MBA, FACP, MCCM, chief medical officer for The Center for Case Management and ICU attending physician at Baystate Medical Center in Springfield, MA, recently studied the effects of COVID-19 on patient severity of illness and how it can affect hospital performance.
Expected Mortality Rates Differ
In a 2021 study, Higgins and colleagues found COVID-19 is different than regular viral pneumonia in terms of expected mortality.1
“COVID patients are sicker,” Higgins says. “Even using a risk-adjustment tool, such as APACHE [Acute Physiology and Chronic Health Evaluation], a hospital’s outcomes are going to look worse than expected, thanks to COVID.”
Higgins notes patients with COVID-19 not only experience a higher mortality rate, but also a longer length of stay than other viral illness patients, even when adjusted for other patient factors such as age and comorbidities.
Because of this, it is a challenge to evaluate hospital performance during the pandemic.
“When it comes to hospital mortality rates, you have to consider patient mix,” Higgins explains. “What kinds of patients is the hospital seeing? If you’re at a hospital doing a lot of ‘bread-and-butter’ cases, your unadjusted mortality rate will likely be average. But at a referral hospital, such as Baystate or the Cleveland Clinic or Mass General, unadjusted mortality will be higher than at a community hospital because academic centers accept difficult cases in transfer from the community. Normally, a benchmarking tool such as APACHE or the Mortality Probability Model helps adjust for these systematic differences in presenting severity of illness. These tools help a hospital calculate standardized mortality ratio [SMR], which is the observed divided by the expected mortality rate. An SMR of 1.0 suggests a hospital is performing as expected. Standardized ratios can also be calculated for length of stay, ventilator days or other outcomes. But COVID presents a challenge, since accurate coefficients for a novel diagnosis have not yet been determined. What we know is that using the corrections for usual viral pneumonia, with or without acute respiratory distress syndrome, are insufficient.”
Effects on Benchmarking Efforts
For hospitals taking in many patients with COVID-19, there is concern quality of care has declined, as performance numbers are looking worse than prior years.
“I’ve gotten calls from clients at The Center for Case Management, and many are saying, ‘We are looking worse this year than we ever have,’” Higgins shares. “But patient flow issues due to longer length of stay doesn’t necessarily mean the care has changed. It means that the patients are qualitatively different than what we’re used to.”
But how can hospitals adjust and know how to appropriately benchmark their performance, especially in an unstable situation like COVID-19, with its ever-evolving variants? Higgins recommends hospitals keep in mind the higher mortality rate and longer length of stay of patients with COVID-19 — a reality that can quickly drive entire hospital statistics higher, as these patients have an “outsized influence on overall mortality rate.”
Data from APACHE revealed that in a group of 43 hospitals throughout the country that contribute to the database, length of stay has increased. Ventilator days averaged 10.4 days for patients with COVID-19 vs. 4.3 days for typical viral pneumonia patients.1
“The APACHE research team has determined that standardized ratios are about 1.5 times higher for COVID-19 vs. viral pneumonia patients,” Higgins explains. “But it’s a changing situation with alpha vs. delta vs. omicron variants, evolving therapeutic interventions, and the impact of vaccination, which is shifting population characteristics.”
The effect of the pandemic on non-COVID-19 patients also should be considered.
“Due to hospital capacity constraints, even non-COVID patients have been found to have a higher mortality rate and longer length of stay,” Higgins notes. “People had been delaying care and coming in later. We have ongoing staffing shortages that are spreading nurses and doctors thinner. Even in the ICU, the usual 1:2 nurse-to-patient ratio might be stretched to a 1:3 ratio, or worse.”
The lack of ICU beds, longer ED waits, and delays in care for patients who must bypass the nearest hospital when on diversion all potentially contribute to a higher mortality rate for non-COVID-19 patients, Higgins says.
“We have preliminary evidence from the APACHE database that SMR in non-COVID patients increases during times of high COVID census,” he explains. “These data have been published as a letter,2 and we’re currently preparing a more detailed study for publication.”
Case Management Concerns
Case managers should note the effects of COVID-19 extend beyond the hospital setting, affecting case management work in several ways. Case managers should remember the following:
- Capacity constraints are extending to home healthcare, skilled nursing facilities, and other post-acute areas, affecting discharge planning.
- There is more competition for a limited supply of resources, which also can cause delays. Even durable medical equipment and drug availability have been disrupted.
- Staff shortages and capacity issues prevent patients from moving from the ED to an inpatient or observation bed.
- Length of stay is affected not only by the higher severity of COVID-19 patients, but also by shortages and lack of resources.
- Margins and finances will look different, as it is harder to care for patients in an economically sustainable manner when they are waiting around the hospital longer.
There is not much case managers can do beyond “casting a wider net as to where to place patients,” Higgins says. “They should also expect that this will be a longer and more difficult process to get from acute to post-acute. Hospitals and case managers alike should also adjust their expectations, but we are not yet sure if we’ll ever get back down to pre-pandemic levels of performance due to patients delaying healthcare. It may be a permanent increase.”
REFERENCES
- Higgins TL, Stark MM, Henson KN, Freeseman-Freeman L. Coronavirus disease 2019 ICU patients have higher-than-expected Acute Physiology and Chronic Health Evaluation-adjusted mortality and length of stay than viral pneumonia ICU patients. Crit Care Med 2021;49:e701-e706.
- Higgins TL, Freeseman-Freeman L, Henson KN, Ringle E. The authors reply. Crit Care Med 2021;49:e1272-e1273.
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