State reveals more info about NC COVID-19 hospital cases, but large gaps remain

by Julie Havlak

Raleigh, NC – North Carolinians know more about COVID-19 hospitalizations than they did a week ago. But data critical to the fight against COVID-19 remain missing from North Carolina’s dashboard, researchers say. 

coronavirus news on screen
Photo by Markus Spiske

North Carolina’s new dashboard shows a regional picture of hospital capacity and COVID-19 hospitalizations. The state began breaking down COVID-19 hospitalizations by region and bed type on Friday, July 17.

The upgrade is a big improvement, but it still leaves unanswered questions and gaps in data, says Joe Coletti, John Locke Foundation senior fellow.

Cooper administration officials say the data help the governor decide about school and business reopenings, travel, public gatherings, and other economic and social activities. What North Carolinians don’t know can lead to confusion over and distrust of official actions. 

Hospitals aren’t required to report COVID-19 patients. The state doesn’t publish the demographics of hospitalized patients. It withholds information about age, race, ethnicity, and gender. And the eight regions the state has designated offer wide variations in access to care. 

The gaps leave the public and researchers in the dark about local hospitalizations, how quickly hospitals in a local area could become overwhelmed by COVID admissions, and the sorts of living and working arrangements may make people more vulnerable to getting hospitalized with the virus, among others.

Carolina Journal spoke with several experts on the data and what it could reveal. CJ contacted the N.C. Department of Health and Human Services and got no response.

Here’s a look at what the state shares about COVID-19 hospitalizations, and what it doesn’t:

Can I track COVID-19 hospital patients and hospital capacity in my area?

Yes and no. 

The new presentation divides the state into eight regions. Residents can track how many general hospital beds, ICU beds, and ventilators by region are available, along with how many COVID-19 patients are in general hospital beds and ICU beds. 

But those eight regions don’t fully show geographic differences in hospital capacity. Nor are all of them contiguous, meaning connected. (See the MCRHC and DHPC regions in the map below.)

The central part of the state and the southeastern tip are in regions covering fewer than 10 counties. But the state’s east and west are each rolled into regions covering large territories. 

Asheville shares a region with Graham County, one of the state’s poorest health care deserts. Two regions contain counties encompassing the southern and northern borders of the state.

Regional variation matters. Researchers expect to see virus microsurges in individual communities, says Julie Swann, head of the Department of Industrial and Systems Engineering at N.C. State University. She served as a science adviser for the Centers for Disease Control and Prevention’s H1N1 pandemic response.

“Even though it’s a single state, this pandemic is experienced by communities that have great differences between them,” Swann told CJ. “You might have plenty of beds for the whole state, but in the western part of the state, where there’s a microsurge, you might be completely out of beds for that region. That’s happened in Houston [Texas].” 

In rural areas, the differences in hospital capacity are stark, says Rachel Graham, assistant epidemiology professor in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill.

“In regional hospitals, you’re talking about maybe eight beds in an ICU,” Graham told CJ. “That’s a significant hurdle to health care capacity. You can’t have too many patients who are severe, because you can’t treat them in a local hospital. Especially if they are dependent on a ventilator.”

North Carolina doesn’t break down hospitalizations by county, but a few other states do. Tatyana Kelly, a N.C. Healthcare Association vice president, called for a “delicate balance” in reporting.

“It’s one thing to report that for Wake and Mecklenburg,” Kelly told CJ. “But when you do that for smaller counties, you don’t want to veer into patient privacy concerns.”

But knowing geographic differences is critical to preventing unnecessary deaths and reopening the economy, said Pinar Karaca-Mandic, University of Minnesota professor and project lead of the national Hospitalization Tracking Project.

“People should not die because the hospital system fails,” Karaca-Mandic told CJ. “What are the capacity constraints that we need to work with? … Knowing that is the critical question in managing this disease.”

How many COVID-19 patients are in the ICU beds and general hospital beds?

On July 21, North Carolina had 1,179 hospitalizations, with 324 patients in intensive care units. Check out the snapshot below for how that breaks down across the state’s eight regions:

What did we know about hospitalizations and hospital capacity before the upgrade?

Not much. North Carolina reported the number of COVID-19 hospital patients and statewide estimates of hospital capacity.

But it didn’t report COVID-19 hospitalizations by geographic region, bed type, demographic, or by patients who are suspected to have COVID-19, but haven’t gotten a positive test result. Residents couldn’t see where hospital admissions were increasing. 

The state’s data on hospital capacity was also murky. There was only a statewide estimate of available hospital beds and ventilators. Researchers didn’t know regional differences in patients’ access to care. 

“We’re operating in a dark, grey space,” Coletti said after the update. “It’s not black anymore, because we’ve been able to shed some light on the situation. But it’s still charcoal.”

Does the public know anything about who’s in the hospital? 

No. North Carolina doesn’t break down hospitalizations by race, age, ethnicity, or gender. It only gives this information for deaths and cases. 

The 1,179 patients hospitalized on July 21 with COVID-19 occupied 6.3% of general hospital beds and 14.3% of ICU beds across the state. But this says little about COVID-19 cases within the hospitals — how many ICU beds were used in a hospital versus how many were available.

Without that data, said Karaca-Mandic, researchers cannot investigate racial and ethnic disparities in the number of patients who are hospitalized with the virus. 

African Americans accounted for 24% of cases and 33% of deaths. Hispanics took up 43% of cases and 10% of deaths. But researchers don’t know how race or ethnicity affects people’s odds of getting hospitalized with the virus in N.C. 

Not publishing patients’ ages creates a different problem. 

Ages provide essential clues about hospital capacity. Older patients tend to require longer, more intense care. Knowing patients’ ages would help researchers estimate how many people will need scarce ICU beds. Without that information, the risk of overwhelming hospitals remains unclear.

Karaca-Mandic also wants to see a breakdown of patients from long-term care facilities and meat-packing plants who were hospitalized. 

“We don’t have the answer,” Karaca-Mandic said. The breakdown would help researchers understand who was hospitalized and where they came from.

Are hospitals required to report COVID-19 patients?

No. Hospitals choose whether to report COVID-19 patients. Not all of them do. Researchers want to see that change.

The percentage of hospitals reporting to the state fluctuates by the day and by the region. When the percentages change, so does the public’s understanding of hospital capacity and the number of hospitalizations.

Across the state, 92% of hospitals shared that data on Tuesday, July 21. But that number contains significant regional variation, depending on the day. 

On Monday, July 20, half of the state’s eight regions had less than 90% of hospitals reporting. Two regions clocked in at less than 70%. The hospital region surrounding Wake County achieved 100% reporting — the only one to do so. 

“If they can require bowling alleys to be closed, it seems like they should be able to require hospitals to report information,” Coletti said. “If you’re going to disrupt the rest of the world to help hospitals, it’s up to hospitals to tell us how they’re being disrupted.” 

The lack of consistent reporting obscures not only hospitals’ capacity but also the number of hospitalizations.

“The more complete the data is, the better it is. Is COVID a reportable disease? Of course it is, the way it’s affecting health care, people’s housing, mortality, businesses,” Karaca-Mandic said. “Hospitals collect this data. They should be mandated to report this data.”

Are patients diagnosed with COVID-19 but hospitalized for something else getting counted toward the state’s COVID-19 hospitalizations? 

Yes. The figures count patients who were admitted to the hospitals for other reasons, and who tested positive for COVID-19 and were put on infection prevention precautions.

“When you think about the role of elective procedures, a lot of our health systems are doing pre-screening. They’ll screen you as an outpatient, then depending on the results, they make a decision on whether this is the time to do an elective procedure or not,” Dr. Betsey Tilson, the state’s chief medical officer, said during a June press briefing. “So [the classifications] may be playing a small role. But I don’t think it’s playing the majority of the role.”

What is the average length of a hospital stay over time?

Unclear. The state estimated the median recovery time for hospitalized COVID-19 patients as 28 days from the date of COVID-19 testing.

Researchers say more detailed information would help gauge how a virus surge would hit hospitals. 

How does North Carolina compare to other states?

Every U.S. state reports different data. All report data differently. 

The lack of coherent, consistent data provoked researchers to launch their own websites and in April email officials from all 50 states. 

“One of the greatest barriers to good decision making is the absence of data,” Karaca-Mandic wrote in Health Affairs in April. “Currently, the only consistent and reliable daily data point available from all 50 states is the number of deaths.”

Half of U.S. states break down their hospitalization data for the public. Twenty-six states report how many COVID-19 patients are in intensive care units. Another 22 states publish the number of patients who are on a ventilator. At least six other states map hospitalizations regionally.

North Carolina’s recent update vastly improved how its data collection compares to other states. But it still lags behind Arizona’s demographic data on hospitalizations, and it doesn’t break down hospitalizations by county.  

Arizona gives the age, race, ethnicity, gender, and county of its hospital patients. In Florida, residents can see which counties are hot spots for COVID-19 hospitalizations. The Sunshine State released county hospitalization data on July 10 after drawing criticism for withholding information.