As COVID admissions surge, states conflating patients hospitalized 'due to' and 'with' virus

States throughout the U.S. are failing to distinguish between patients hospitalized because of COVID-19 and patients who merely test positive for the disease while being hospitalized for other reasons.

Hospitalizations have for months been viewed as one of the critical indicators of the coronavirus pandemic: Countries worldwide have relied heavily on the number of patients sent to hospitals because of the virus as a way of measuring how severe a region or a nation's outbreak really is. 

In the United States, as in most other countries, one of the chief concerns of the pandemic has been whether or not hospitals have enough capacity to treat surges in COVID patients in addition to more routine procedures and emergency issues. The most recent surge in positive COVID-19 tests, which began in early October, has led to record highs of hospitalized COVID-positive patients.

The COVID Tracking Project, a group of public health experts and journalists who have been collecting COVID-19 data from state health departments since early 2020, currently lists over 125,000 hospitalized COVID patients nationwide, roughly double the earlier peaks seen in the spring and summer. 

Differentiating between 'with' and 'due to'

Yet many, if not most, states are failing to make the distinction between patients hospitalized because of COVID-19 versus those who simply test positive for the disease while hospitalized for something else, according to a Just the News survey of state health departments. 

That data would provide a fuller picture of both the pandemic and its toll on local medical systems. Yet state public health officials consistently told Just the News that their respective health departments do not track that data. 

"The number posted [on the state's dashboard] is for hospitalized patients, so those numbers represent people who are being treated for COVID-19 in an inpatient setting," said Elizabeth Goodsitt, a spokeswoman with the Wisconsin Department of Health Services. "There may be other things going on with them, but they are included in that number if they are COVID-19 positive and admitted to the hospital for care."

Marisa Maez, a spokeswoman with the New Mexico Department of Health told Just the News: "When the state releases its daily COVID count, all COVID related hospitalizations are counted which includes those who are specifically hospitalized for COVID and those that test positive while hospitalized for other conditions."

Mississippi state epidemiologist Paul Byers said: "The hospitalization numbers reported to us daily represent the number of people hospitalized with confirmed COVID 19 infection, the number of people in the ICU with confirmed COVID-19, and the number of people on ventilators with confirmed COVID-19." The numbers reflect "patients hospitalized with confirmed COVID-19 infection," regardless of their reason for admittance, Byers confirmed.

"The number of COVID-19-related hospitalizations reported is for all patients in the hospital with a lab-confirmed diagnosis of COVID-19, whether it is the primary diagnosis or a secondary one," said Charlie Gischlar with the Maryland Department of Health. 

Connecticut Department of Health spokeswoman Maura Fitzgerald said the state's hospitalization numbers encompass "the number of patients anywhere in the facility that are currently positive with COVID-19."

The Colorado Department of Public Health and Environment said the state's numbers "include confirmed cases, and those who are under investigation for having COVID. Those under investigation could be hospitalized as a result of COVID symptoms but haven't been tested or they could be there for another reason. The same would be true for the confirmed cases."

The number of total hospitalizations in California "represents all who are hospitalized with COVID-19, including those being treated for other medical issues," the California Department of Public Health told Just the News. 

Spokeswoman Karen Landers with the Alabama Department of Public Health said the state "classifies cases of COVID-19 as persons with positive PCR for SARSCoV2," while the department "does not sub categorize cases that are hospitalized."

Lynn Sutfin, a spokeswoman with the Michigan Department of Public Health told Just the News that the state defines a COVID hospitalization as any patient "currently hospitalized in an adult inpatient bed who have laboratory-confirmed or suspected COVID- 19."

'This is a crucially important topic'

Experts who spoke with Just the News affirmed the importance of this data point in determining the overall extent of the pandemic. 

Jay Bhattacharya, a professor of medicine at Stanford University, said that it is "very likely that many patients who are listed as dying from COVID had underlying medical issues that make the designation of COVID as the primary cause problematic."

"However, to the best of my knowledge, there has not been a definitive study that has measured the extent of this problem," he said. "This is something I am actively working on.  It is a hard question to answer without a lot of careful analysis of the health records of COVID-19 patients."

Martin Kulldorff, a medical professor at Harvard University, agreed that the missing data raised a "related and equally important question" of "how many of the reported COVID deaths are due to versus with COVID."

"The Östergötland Region in Sweden did a thorough study of whether reported COVID-19 deaths were because of COVID or with COVID," Kulldorff continued. "At the time of the study, there had been 245 reported COVID-19 deaths in the region, 123 at hospitals and 122 at home or in care facilities. They wrote desperate reports for the two groups, but if we combine them, they found that of the 245 deaths, 61 (25%) were primarily due to COVID-19, 60% had COVID-19 as a contributing cause, while 36 (15%) were unrelated to COVID-19."

"Of course, these percentages are bound to be different in different countries," he continued. "It is important to do these studies in every country, but I am not aware of any other equally thorough study on this topic."

Some health officials who spoke to Just the News downplayed the possibility patients who merely test positive for the virus could form a substantial percentage of overall COVID patients. 

The Delaware Department of Public Health told Just the News that the number of hospitalized patients reported by the state "includes any individual who is hospitalized and has a positive test for COVID-19."

"However, anecdotally, it does not appear that incidental COVID-19 positive cases among hospitalized patients (i.e. those who are there for other reasons and then test positive for COVID) are common," the department continued, "but rather it is more common that the hospitalization is related to illness from COVID-19."

Joseph Wendelken with the Rhode Island Department of Health, meanwhile, told Just the News that the state's hospitalization number reflects "all hospitalized patients with lab-confirmed COVID-19" and that the state uses that broader classification "because when a hospital patient has COVID, that places a strain on the hospital, even if that person was not hospitalized because of COVID."

The proportion of U.S. patients hospitalized with an incidental COVID-19 diagnosis may ultimately never be known due to the limitations in state-gathered data. Yet in at least one case where that data was known, the total number of secondary COVID-19 diagnoses among hospitalized patients was significant: North Dakota on its state dashboard used to make that distinction, and a survey of those numbers in November showed that about 40% of the total number of COVID patients in the state were hospitalized "with" the disease rather than strictly because of it. 

If those numbers were extrapolated nationwide, that would mean that, of the current record 125,000 coronavirus hospitalizations in the U.S., 75,000 of them would be patients suffering from a primary COVID-19 diagnosis — relatively little increase from the earlier peaks of around 60,000, which themselves may have been similarly inflated. 

Yet states have shown no indication that they plan to begin making those distinctions. Indeed, North Dakota several weeks ago removed its own sub-analysis of those numbers from its state dashboard. State Department of Health spokeswoman Nicole Peske told Just the News that the state "updated it a month or two ago and removed the WITH COVID because the way we had to pull the data to get the number was causing confusion."

Peske did not respond when asked what kind of confusion that number was causing and whether the state has continued to monitor those numbers internally even as it has ceased displaying them publicly.