(1166) Impact of Hospital Size on COVID-19 Outcomes in the United States

Introduction: The COVID-19 pandemic posed substantial challenges to healthcare systems worldwide. In addition to patient characteristics, the nature of hospitals may have significantly influenced patient outcomes. Currently, there are no data on the impact of hospital size on outcomes. We aimed to investigate potential variations in patient outcomes based on hospital size within the US.

Methods: The study population comprised a total of 1,018,915 patients, who were older than 18 years admitted with a primary diagnosis of COVID-19 from the National Inpatient Sample (NIS) database for 2020. Employing a retrospective analysis, we compared inpatient mortality rates in medium-sized and large hospitals to those in small hospitals. We used both univariate and multivariable linear and logistic regression models. We adjusted the multivariable models to account for confounding factors, including age, gender, race, insurance status, median income, comorbidity burden, hospital region, location, and teaching status. Secondary analyses were performed for the need for non-invasive (NIV), invasive (IMV), and IMV within 24 hrs, length of stay, and total hospitalization charges.

Results: We found that inpatient mortality rates in medium-sized (OR 1.15 (1.07-1.24), p < 0.001) and large (OR 1.19 (1.11-1.27), p< 0.001) hospitals were higher in comparison to small hospitals. Furthermore, small hospitals demonstrated shorter lengths of stay and lower hospitalization costs when compared to both medium-sized and large hospitals. While no significant difference was observed in the need for NIV, the odds of IMV were higher in medium-sized and large hospitals. Odds of early IMV were higher in large hospitals as opposed to small hospitals.

Conclusions: Hospital size impacted patient outcomes during COVID-19. Medium-sized and large hospitals had poorer outcomes and higher resource utilization. The increased resource utilization in larger hospitals could be attributed to the availability of more advanced investigative and treatment options. Limited access to advanced management in small hospitals led to transferring sicker patients to larger hospitals for specialized care, potentially explaining higher inpatient mortality rates. Tailoring responses based on resources enhances preparedness for future crises, improving patient care.