Editor's Note: This is a complimentary research note published by Healthcare Policy analyst Emily Evans. CLICK HERE to get COVID-19 analysis and alerts from our research team and access our related webcasts.
Florida has always been data-focused when it comes to health care. During COVID-19, they are producing some of the richest datasets on demographics, hospitalizations, and emergency visits at the county level.
Of particular interest to anyone trying to evaluate hospital impacts for future outbreaks is the caseline data. The caseline data has profiles for about 400,000 people including age, gender, whether they visited the ER and/or were hospitalized.
The time series provides a good bit of insight into how the Florida COVID-19 outbreak has changed over the last several months, particularly as it relates to impacts on hospitals. Early in the outbreak most confirmed cases were triggered by a symptomatic person engaging the health system, most typically through an ER visit.
As testing became more widely available and the requirements normally associated with a diagnostic test, such as a doctor's order, were waived and the indications for a test expanded, confirmed cases have become less a measure of the presence of disease and more about infection spread.
Whereas early in the outbreak, a confirmed case was almost always associated with illness, often serious, and possible death, today the connection is more tenuous.
Throughout April and May, a case that entered the ER was almost always hospitalized. In June the trends diverged. An individual entering the ER and confirmed as infected with SAR-CoV-2 was admitted only about half the time. The different response to a patient presenting in the ER has a lot to do with age.
On May 31, 26% of confirmed cases were under 35. As of yesterday, 42% of cases were under 35. Younger people are less at risk for serious illness, a fact reflected in the paltry 9% of the 20,000 hospitalized for cases attributable to people under 35, as of yesterday.
Death is an even more remote outcome; 1% of the deaths occured in people under 35, a figure that has been consistent throughout the outbreak in Florida.
As testing has expanded, a result of both availability and changes to indications, case counts have become less relevant to hospital impact. At the beginning of the outbreak, anywhere from 25-60% of confirmed cases were associated with an ER visit. Today the figure is less than 2%.
As ER visits as a percent of confirmed cases has declined, so have hospitalizations.
The data on ER visits and hospitalizations, while an encouraging sign of the health system's ability to cope with outbreaks, does ignore the very regional nature of disease spread. Hard hit counties like Miami-Dade, Broward, Hillsborough and Orange experienced capacity constraints on available beds, especially in smaller hospitals, dropping to low single digits.
On Jul 10, the day before Florida experienced peak daily case volume, of 309 Florida hospitals in the ACHA database, 284 reported bed census.
Of the reporting hospitals, 141, representing about 35,000 staffed beds had available capacity below 20%. At the same time, overall state bed capacity was 19.71% of the 60,000 staffed beds.
The state-wide ER and hospitalization data also ignores other impacts. Concerns about contracting COVID-19 may be leading to voluntary deferral of care. On July 10, there were 99 hospitals, representing 11,000 staffed beds, reporting available capacity over 30%.
Some hospitals in unaffected areas like the panhandle and central Florida were reporting available capacity above 50%. There are other explanations. Reduced international and domestic summer travel has probably created fewer unplanned admissions due to a diminshed number of accidents or other causes for hospitalizations, for example.
As of July 23rd, there were 128 Florida hospitals operating below 20% available capacity, representing about 30,000 staffed beds. Unfortunately, there were still 99 hospitals operating at available capacity in excess of 30%, representing 14,000 staffed beds. The abatement of serious COVID-19 infections at Florida hospitals, especially in hard hit areas, is not translating into higher occupancy throughout the state, at least not yet.
We should not be the drunk looking for his keys under the streetlamp.
Every state is a little different and outbreaks have their own nuances depending on the population attacked and the demographics of a particular area. Houston, counties along the border in Arizona, and California and the pending outbreak in Idaho, will all suggest different impacts to hospitals.
The experience of Florida, however, does suggested a muted recovery for hospitals whether due to COVID-19 case demands or general concerns about hospital care, especially for the more vulnerable populations.