Variation in US Hospital Mortality Rates for Patients Admitted With COVID-19 During the First 6 Months of the Pandemic

Importance It is unknown how much the mortality of patients with coronavirus disease 2019 (COVID-19) depends on the hospital that cares for them, and whether COVID-19 hospital mortality rates are improving. Objective To identify variation in COVID-19 mortality rates and how those rates have changed over the first months of the pandemic. Design, Setting, and Participants This cohort study assessed 38 517 adults who were admitted with COVID-19 to 955 US hospitals from January 1, 2020, to June 30, 2020, and a subset of 27 801 adults (72.2%) who were admitted to 398 of these hospitals that treated at least 10 patients with COVID-19 during 2 periods (January 1 to April 30, 2020, and May 1 to June 30, 2020). Exposures Hospital characteristics, including size, the number of intensive care unit beds, academic and profit status, hospital setting, and regional characteristics, including COVID-19 case burden. Main Outcomes and Measures The primary outcome was the hospital's risk-standardized event rate (RSER) of 30-day in-hospital mortality or referral to hospice adjusted for patient-level characteristics, including demographic data, comorbidities, community or nursing facility admission source, and time since January 1, 2020. We examined whether hospital characteristics were associated with RSERs or their change over time. Results The mean (SD) age among participants (18 888 men [49.0%]) was 70.2 (15.5) years. The mean (SD) hospital-level RSER for the 955 hospitals was 11.8% (2.5%). The mean RSER in the worst-performing quintile of hospitals was 15.65% compared with 9.06% in the best-performing quintile (absolute difference, 6.59 percentage points; 95% CI, 6.38%-6.80%; P < .001). Mean RSERs in all but 1 of the 398 hospitals improved; 376 (94%) improved by at least 25%. The overall mean (SD) RSER declined from 16.6% (4.0%) to 9.3% (2.1%). The absolute difference in rates of mortality or referral to hospice between the worst- and best-performing quintiles of hospitals decreased from 10.54 percentage points (95% CI, 10.03%-11.05%; P < .001) to 5.59 percentage points (95% CI, 5.33%-5.86%; P < .001). Higher county-level COVID-19 case rates were associated with worse RSERs, and case rate declines were associated with improvement in RSERs. Conclusions and Relevance Over the first months of the pandemic, COVID-19 mortality rates in this cohort of US hospitals declined. Hospitals did better when the prevalence of COVID-19 in their surrounding communities was lower. Question Are hospital outcomes for patients with coronavirus disease 2019 (COVID-19) improving? Findings In this cohort study of 38 517 adults who were admitted with COVID-19 to 955 US hospitals, rates of 30-day mortality or referral to hospice varied from 9.06% to 15.65% in the best- and worst-performing quintiles. In the early months of the pandemic, 94% of hospitals in a subset of 398 improved by at least 25%, and the strongest determinant of improvements in hospital-level outcome was a decline in community rates of infection. Meaning All else being equal, COVID-19 mortality in hospitals seems to be lower when the prevalence of COVID-19 in their surrounding communities is lower. This cohort study examines variations in COVID-19 mortality rates and over the first 6 months of the pandemic.