Hospital Safety-Net Burden and Outcomes of COVID-19 Hospitalizations in the US: Analysis of a National Multicenter Database

BackgroundSafety-net hospitals (SNH) provide care to a significant proportion of low-income, uninsured, and underserved populations disproportionately affected by the COVID-19 pandemic. We evaluated the impact of safety-net burden on outcomes of COVID-19 hospitalizations.MethodsWe identified patients aged ≥ 18 years hospitalized with COVID-19 from the nationwide inpatient database using the International Classification of Diseases, Tenth Edition (ICD-10-CM) code U07.1. The primary study outcomes were inpatient mortality, respiratory failure requiring mechanical ventilation, and tracheostomy use. Secondary outcomes were total hospitalization costs (THC) and length of hospital stay (LOS). Multivariable logistic regression was used to compare the primary and secondary outcomes in HBH and medium safety-net burden (MBH) with lower-burden hospitals (LBH) (reference).ResultsAn estimated 2,608,232 COVID-19 hospitalizations met the inclusion criteria, with 68.7% occurring in HBH, 22.8% in MBH, and 8.5% in LBH. On adjusted multivariable analysis, HBH was associated with increased odds of inpatient mortality (aOR 1.19, 95% CI 1.09-1.28) compared with LBH. Both HBH (aOR 1.30, 95% CI 1.21-1.40) and MBH (aOR 1.14, 95% CI 1.06-1.24) demonstrated increased odds of mechanical ventilation compared with LBH. THC was lower in HBH and MBH compared with LBH. The LOS was similar across safety net burden categories.ConclusionAfter adjusting for patient- and hospital-level factors, COVID-19 hospitalizations at HBH had inferior inpatient outcomes compared with LBH. Targeted policy reforms are needed to address the underlying causes of these disparities and increase our health systems' readiness for future crises, particularly in underserved communities.