Publications

OBJECTIVE

Studies describe COVID-19 patient characteristics and outcomes across populations, but reports of variation across healthcare facilities are lacking. The objectives were to examine differences in COVID-19 patient volume and mortality across facilities, and understand whether facility variation in mortality was due primarily to differences in patient versus facility characteristics.

DESIGN

Observational cohort study with multilevel mixed effects logistic regression modelling.

SETTING

The Veterans Health Administration (VA) is the largest healthcare system in the USA.

PARTICIPANTS

Patients with COVID-19.

MAIN OUTCOME

All-cause mortality within 45 days after COVID-19 testing (March-May, follow-up through 16 July 2020).

RESULTS

Among 13 510 patients with COVID-19, 3942 (29.2%) were admitted (2266/3942 (57.5%) ward; 1676/3942 (42.5%) intensive care unit (ICU)) and 679/3942 (17.2%) received mechanical ventilation. Marked heterogeneity was observed across facilities in median age (range: 34.3-83.9 years; facility mean: 64.7, SD 7.2 years); patient volume (range: 1-737 at 160 facilities; facility median: 48.5, IQR 14-105.5); hospital admissions (range: 1-286 at 133 facilities; facility median: 11, IQR 1-26.5); ICU caseload (range: 1-85 at 115 facilities; facility median: 4, IQR 0-12); and mechanical ventilation (range: 1-53 at 90 facilities; facility median: 1, IQR 0-5). Heterogeneity was also observed in facility mortality for all patients with COVID-19 (range: 0%-29.7%; facility median: 8.9%, IQR 2.4%-13.7%); inpatients (range: 0%-100%; facility median: 18.0%, IQR 5.6%-28.6%); ICU patients (range: 0%-100%; facility median: 28.6%, IQR 14.3%-50.0%); and mechanical ventilator patients (range: 0%-100%; facility median: 52.7%, IQR 33.3%-80.6%). The majority of variation in facility mortality was attributable to differences in patient characteristics (eg, age).

CONCLUSIONS

Marked heterogeneity in COVID-19 patient volume, characteristics and mortality were observed across VA facilities nationwide. Differences in patient characteristics accounted for the majority of explained variation in mortality across sites. Variation in unadjusted COVID-19 mortality across facilities or nations should be considered with caution.

BACKGROUND

The COVID-19 pandemic and associated public health prevention measures (e.g., "stay at home" orders) may impact tobacco supply and demand among consumers. This qualitative study identified multi-level drivers of shifts in inhaled tobacco product use and access patterns during the initial COVID-19 "lockdown" period in the United States.

METHODS

Between April and May 2020, we conducted semi-structured telephone interviews (n = 44) with adults who use cigarettes and/or electronic nicotine delivery systems (ENDS). Transcripts were thematically analyzed using a socioecological framework.

RESULTS

Nearly all participants reported changes in their product use during lockdown, though patterns varied. Increased use was most common and was predominantly driven by individual-level factors: pandemic-related anxiety, boredom, and irregular routines. Decreased use was common among social users who cited fewer interpersonal interactions and fear of sharing products. At the community level, retail access impacted cigarette and ENDS use differently. While cigarettes were universally accessible, ENDS access was more limited, driving some to purchase products online. Delayed deliveries led some ENDS users to compensate with readily-available cigarettes.

CONCLUSION

To mitigate ways that the COVID-19 pandemic may exacerbate an existing public health crisis, multi-level policy strategies, such as expanded virtual cessation services and implementation and enforcement of smoke-free home rules, can better support population health during this critical period. Policies that facilitate access to lower risk products can help minimize harm among those who cannot or do not want to quit smoking.