The COVID-19 Pandemic Strikes Again and Again and Again

The COVID-19 pandemic has proven relentlessly challenging for health care. Although some positive consequences have resulted from these challenges, including the move to routine virtual health care and the increased attention on staffing and supply chain sustainability, these positive consequences have been overwhelmed by the pandemic’s negative impacts on health. Dang et al¹ tally yet one more adverse outcome of COVID-19: among Medicare patients, mortality after hospitalization for non–COVID-19 diagnoses increased significantly. In a retrospective study of more than 8.4 million Medicare admissions between January 2019 and September 2021 occurring at 4626 US hospitals, 30-day risk-adjusted mortality among patients without COVID-19 increased by more than 20%, from 9.43% before COVID-19 to 11.48% after COVID-19.

Perhaps the most striking finding from the study¹ was that increased mortality was observed in hospitals with more COVID-19–related admissions, confirming the far-reaching consequences of COVID-19–related strain on the health care system. Strain, which is defined as nearing or exceeding the limits of the care team’s ability to provide high-quality care to all patients who require it,² is a phenomenon that is intimately familiar to clinicians during COVID-19 but that can be challenging to quantify and study. Strain is typically measured through metrics of how busy the hospital is, such as occupancy, acuity, turnover, admissions, discharges, and/or the need for organ support therapy.³ Prior work³ has shown that during periods of high hospital strain, borderline patients with common illnesses like sepsis and acute respiratory failure are far less likely to be admitted to the intensive care unit compared with periods of low strain. This is a stark example of how strain can impact routine care processes and even patient outcomes in severe illness.

The COVID-19 pandemic has strained health systems around the world in unprecedented ways, with all health systems grappling with limitations in staffing (physicians, nurses, respiratory therapists, and pharmacists), supplies (medications, tests, ventilators, high-flow oxygen machines, and vaccines), and space (hospital beds, subacute nursing facility beds, and dialysis units). During the pandemic’s inpatient surges, COVID-19–specific mortality was already known to increase.⁴ However, the study by Dang et al¹ confirms a lingering concern that clinicians have feared might also be true: elderly patients admitted to hospitals with diagnoses other than COVID-19 are more likely to die during surges, even after adjusting for patient and hospital characteristics. This work is important because it quantifies a very serious source of harm that is not part of the daily COVID-19 case or death counts highlighted in the media.

We are left to wonder what factors are associated with this increased mortality. Multiple studies have shown that health care delivery has changed during COVID-19, and, early on, patients were afraid to present to acute care, so even the incidence of acute myocardial infarction appeared to decrease.⁵ Patients were also presenting for care later in the course of illness because of delays in obtaining diagnostic tests or outpatient appointments.⁶ Were these patterns of delayed or deferred preventive care and management, upstream of hospitalization, major factors associated with increased mortality? Or was suboptimal care during the inpatient phase or posthospital phase, resulting from the strain of COVID-19 surges, associated with the increase in mortality during hospitalizations not related to COVID-19? It is likely that both are contributing because COVID-19 strain has not been localized to just a single domain within health care. Granular insights at the medical record review or on-the-ground interview level will be essential to conduct the necessary root cause analyses.

It is particularly concerning that the increase in mortality described by Dang et al¹ was higher for Black and Hispanic patients compared with White patients. Many previous studies⁷ have already shown that minoritized racial groups account for a disproportionate percentage of COVID-19–related deaths. The results of Dang et al¹ now highlight a similar impact on non–COVID-19 deaths. In addition, the overall increase in mortality persisted through 2021, which indicates that this was not a transient phenomenon observed only in the spring of 2020 as health care systems faced the first challenges related to a lack of testing, personal protective equipment, and treatments.

The COVID-19 pandemic has proven to be far more pervasive and persistent than many first surmised. Fully 2 years into the pandemic, each day brings a new understanding of the massive toll the pandemic has taken on all patients, both with and without COVID-19. Even as the world’s health systems suffer under the overwhelming weight of COVID-19, we must continue to understand and mitigate its direct and indirect impacts, particularly for our vulnerable and disadvantaged populations.

Published: March 9, 2022. doi:10.1001/jamanetworkopen.2022.1760

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Myers LC et al. JAMA Network Open.

Corresponding Author: Vincent X. Liu, MD, MSc, Division of Research and the Permanente Medical Group, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 (vincent.x.liu@kp.org).

Conflict of Interest Disclosures: None reported.