Patient-level and hospital-level variation and related time trends in COVID-19 case fatality rates during the first pandemic wave in England: multilevel modelling analysis of routine data
Patient-level and hospital-level variation and related time trends in COVID-19 case fatality rates during the first pandemic wave in England: multilevel modelling analysis of routine data
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DOI：
10.1136/bmjqs-2021-012990
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发表时间：
2021-07-06
影响因子：
5.4
通讯作者：
Aylin, Paul P.
中科院分区：
文献类型：
--
作者：
Bottle, Alex;Faitna, Puji;Aylin, Paul P.
背景 一份报告表明，英国因 COVID-19 入院后各医院之间的死亡率存在巨大差异，该报告引起了媒体的广泛关注，但使用的是粗率。我们的目的是量化英格兰第一波疫情期间（2020 年 3 月至 7 月）期间医院之间以及随时间推移的这些差异，并评估可用的患者级别和医院级别预测因子来解释这些变化。方法 我们使用英格兰的行政数据，并通过医院级别的信息进行补充。使用 COVID-19 代码提取录取信息。院内死亡是主要结局。使用多级逻辑回归计算风险调整死亡率（标准化死亡率）和医院间变异。比较了早波（三月至四月）和晚波（五月至七月）时期。结果 74 781 例入院者初步诊断为 COVID-19，其中 21 984 例院内死亡 (29.4%)； 30天总死亡率为28.8%。所有年龄段的院内粗死亡率从 3 月份的 32.9% 下降到 7 月份的 13.4%。患者层面的预测因素包括年龄、男性、非白人种族（仅限早期）和多种合并症（仅限早期肥胖）。医院层面唯一重要的预测因素是后期每天的 COVID-19 入院人数；我们没有发现任何时期因 COVID-19 导致的员工缺勤、机械通气床位占用率、总床位占用率或因 COVID-19 入院而导致的床位占用率之间的关系。风险调整后，只有 4 家 (3%) 和 2 家 (2%) 医院处于较高漏斗图死亡率异常值，5 家 (4%) 和 0 家医院在早期和晚期分别处于 3 SD 的低漏斗图死亡率异常值。我们发现早期和晚期医院死亡率之间没有很强的相关性（r=0.17，p=0.06）。结论 经过风险和随机变异调整后，英国医院之间因 COVID-19 入院后的死亡率存在适度差异，这与早期媒体报道形成鲜明对比。早期死亡率并不能预测晚期死亡率。
Background A report suggesting large between-hospital variations in mortality after admission for COVID-19 in England attracted much media attention but used crude rates. We aimed to quantify these variations between hospitals and over time during England's first wave (March to July 2020) and assess available patient-level and hospital-level predictors to explain those variations. Methods We used administrative data for England, augmented by hospital-level information. Admissions were extracted with COVID-19 codes. In-hospital death was the primary outcome. Risk-adjusted mortality ratios (standardised mortality ratios) and interhospital variation were calculated using multilevel logistic regression. Early-wave (March to April) and late-wave (May to July) periods were compared. Results 74 781 admissions had a primary diagnosis of COVID-19, with 21 984 in-hospital deaths (29.4%); the 30-day total mortality rate was 28.8%. The crude in-hospital death rate fell in all ages and overall from 32.9% in March to 13.4% in July. Patient-level predictors included age, male gender, non-white ethnic group (early period only) and several comorbidities (obesity early period only). The only significant hospital-level predictor was daily COVID-19 admissions in the late period; we did not find a relation with staff absences for COVID-19, mechanical ventilation bed occupancies, total bed occupancies or bed occupancies for COVID-19 admissions in either period. Just 4 (3%) and 2 (2%) hospitals were high, and 5 (4%) and 0 hospitals were low funnel plot mortality outliers at 3 SD for early and late periods, respectively, after risk adjustment. We found no strong correlation between early and late hospital-level mortality (r=0.17, p=0.06). Conclusions There was modest variation in mortality following admission for COVID-19 between English hospitals after adjustment for risk and random variation, in marked contrast to early media reports. Early-period mortality did not predict late-period mortality.