ArticleAnnals of internal medicine2021
Association Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020.
Article in Annals of internal medicine, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT04688372 (Association Between Hospital Case Burden and Mortality Risk Among Patients Hospitalized With COVID-19), which is not on this map. Cited by 108 papers, 1 of them a synthesis that pooled it.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Association Between Hospital Case Burden and Mortality Risk Among Patients Hospitalized With COVID-19: A Retrospective Cohort Study of U.S. Hospitals
Who cites it
108 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Guideline
- Hospital Capacity Pooling in Pandemics: Simulation-Based Mortality Impacts and Diversification Mechanisms.Risk analysis : an official publication of the Society for Risk Analysis · 2026Article
- National cost of intensive care in Japan from 2018 to 2022.Journal of intensive care · 2026Article
- Financial Impacts of Receiving Combat Casualties during a Large-Scale Combat Operation on Civilian Hospitals in the NDMS Pilot Study.Disaster medicine and public health preparedness · 2026Article
- Reconstructing severe acute respiratory infection dynamics from ICD-10 hospital discharge data: a 10-year analysis of 11.2 million discharges in Ecuador, 2014-2023.Frontiers in public health · 2026Article
- Statewide Transfer Coordination and Patient Transfer Rates Among Hospitals During Occupancy Stress.JAMA network open · 2025Article
- Beyond the Virus: The Collateral Impact of COVID-19 on Antimicrobial Consumption, Microbial Resistance, and Pharmacoeconomics.Pathogens (Basel, Switzerland) · 2025Observational
- Impact of prefecture-level intensive care unit congestion on mortality in severe COVID-19 patients: a retrospective observational study in Japan.BMC infectious diseases · 2025Observational
- Changing socioeconomic inequalities in the incidence and case fatality rates of COVID-19 in Germany, March 2020 through May 2022: an ecological study.BMC public health · 2025Article
- Trends and Disparities in Mortality due to Diabetes Mellitus and Sepsis in the US Adults: 1999-2023.Endocrinology, diabetes & metabolism · 2025Article
- Acceptability and Feasibility of a Prototype Regional Disaster Teleconsultation System for COVID-19 Pandemic Response: Pilot Field Test.JMIR formative research · 2025Observational
- A modular approach to forecasting COVID-19 hospital bed occupancy.Communications medicine · 2025Article
- Rethinking the evidence on COVID-19 in Africa.The Lancet. Infectious diseases · 2025Review
- Variation in clinical presentation, complications and outcomes for Māori and Pacific peoples among hospitalised adults with COVID-19 in 2022, Aotearoa New Zealand.Internal medicine journal · 2025Article
- The Impact of a Novel Transfer Process on Patient Bed Days and Length of Stay: A Five-Year Comparative Study at the Mayo Clinic in Rochester and Mankato Quaternary and Tertiary Care Centers.International journal of environmental research and public health · 2025Article
- Article
- Article
- A transfer triage tool for COVID-19 mass critical care surges.Scientific reports · 2025Observational
- Enhanced COVID-19 Provider Relief, Hospital Finances, and Care for Medicare Inpatients.JAMA health forum · 2025Article
- Adjunctive linezolid versus clindamycin for toxin inhibition in β-lactam-treated patients with invasive group A streptococcal infections in 195 US hospitals from 2016 to 2021: a retrospective cohort study with target trial emulation.The Lancet. Infectious diseases · 2025Article
48 more citing papers are in PubMed but not listed here.
Corrections and comments
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Authors and funding
24 authors.
Funding
Abstract
backgroundSeveral U.S. hospitals had surges in COVID-19 caseload, but their effect on COVID-19 survival rates remains unclear, especially independent of temporal changes in survival.
objectiveTo determine the association between hospitals' severity-weighted COVID-19 caseload and COVID-19 mortality risk and identify effect modifiers of this relationship.
designRetrospective cohort study. (ClinicalTrials.gov: NCT04688372).
setting558 U.S. hospitals in the Premier Healthcare Database.
participantsAdult COVID-19-coded inpatients admitted from March to August 2020 with discharge dispositions by October 2020. MEASUREMENTS: Each hospital-month was stratified by percentile rank on a surge index (a severity-weighted measure of COVID-19 caseload relative to pre-COVID-19 bed capacity). The effect of surge index on risk-adjusted odds ratio (aOR) of in-hospital mortality or discharge to hospice was calculated using hierarchical modeling; interaction by surge attributes was assessed.
resultsOf 144 116 inpatients with COVID-19 at 558 U.S. hospitals, 78 144 (54.2%) were admitted to hospitals in the top surge index decile. Overall, 25 344 (17.6%) died; crude COVID-19 mortality decreased over time across all surge index strata. However, compared with nonsurging (<50th surge index percentile) hospital-months, aORs in the 50th to 75th, 75th to 90th, 90th to 95th, 95th to 99th, and greater than 99th percentiles were 1.11 (95% CI, 1.01 to 1.23), 1.24 (CI, 1.12 to 1.38), 1.42 (CI, 1.27 to 1.60), 1.59 (CI, 1.41 to 1.80), and 2.00 (CI, 1.69 to 2.38), respectively. The surge index was associated with mortality across ward, intensive care unit, and intubated patients. The surge-mortality relationship was stronger in June to August than in March to May (slope difference, 0.10 [CI, 0.033 to 0.16]) despite greater corticosteroid use and more judicious intubation during later and higher-surging months. Nearly 1 in 4 COVID-19 deaths (5868 [CI, 3584 to 8171]; 23.2%) was potentially attributable to hospitals strained by surging caseload. LIMITATION: Residual confounding.
conclusionDespite improvements in COVID-19 survival between March and August 2020, surges in hospital COVID-19 caseload remained detrimental to survival and potentially eroded benefits gained from emerging treatments. Bolstering preventive measures and supporting surging hospitals will save many lives. PRIMARY FUNDING SOURCE: Intramural Research Program of the National Institutes of Health Clinical Center, the National Institute of Allergy and Infectious Diseases, and the National Cancer Institute.
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