For the past two and a half years, U.S. hospitals have routinely screened newly admitted patients for SARS-CoV-2 infection. Hospitals report every SARS-CoV-2 positive patient who dies in the hospital as a COVID-19-related death.
In the early phases of the pandemic, that practice made sense. We needed an easy-to-understand measure that was generalizable across all states to monitor the mortality of COVID-19. We strove to avoid undercounting COVID-19 deaths because many individuals who might have died from COVID-19 were never tested for COVID-19 or died at home. But counting every SARS-CoV-2 positive death as a COVID-19-related death no longer provides us meaningful information — and worse — results in several harms.
Death certificates in the United States are notoriously inaccurate, either under or over-reporting the associated mortality of numerous diseases. For diseases such as cancer, a complex system is required to accurately count deaths — a system dependent on state-supported cancer registries and death certificate reviews at the cost of millions of dollars a year. Such a system of verification exists for COVID-19-related deaths only in a few counties across the country. Therefore, it is difficult to determine if the patients who die in the hospital with COVID-19 have died from COVID-19.
Because every newly hospitalized patient is tested for COVID-19 on admission, we can expect that among the total daily deaths, a certain percentage proportional to the level of COVID-19 in the community will be reported as COVID-19-related deaths. If COVID-19 positivity in the community is 5 percent, then at least 5 percent of hospital-based deaths will be counted as COVID-19-related — whether or not COVID-19 contributed to the patient’s illness.
Assuming that roughly 90 percent of the 9,270 daily deaths occur in a hospital, (about 3.4 million Americans die every year), roughly 417 of those deaths will be among individuals testing positive for COVID-19 in a community with COVID-19 positivity of around 5 percent. Because everyone in the hospital is tested for COVID-19, we expect to label around 400 hospital-based deaths as attributable to COVID-19 because those individuals tested positive (see figure below).
Figure: Expected Daily Deaths due to COVID-19 in Three Modeled Scenarios of Community Positivity Across the United States
Notably, over the past few weeks, the rate of reported COVID-related deaths has stabilized to between 300-500 per day. Thus, among the people who die in hospitals every day from a variety of causes, the number of expected COVID-19 deaths based on test positivity is approximately the same as the number of people being reported as having died because of COVID-19. Medically and epidemiologically, that is a near impossibility.
Further, the actual mortality ratio of COVID-19 (the proportion of patients with COVID-19 who die as a result of COVID-19) has decreased substantially with the numerous treatments now available, preventive medications and effective immunizations. A recent report estimated the overall risk of death among individuals infected with the omicron variant to be about 1 in 10,000. But based on the number of reported cases nationally between March 22 and April 22, the reported death rate was about 4 times higher. COVID-19 deaths are being overcounted by the order of at least fourfold.
To test our hypothesis that COVID-19 deaths are being over-reported, we looked at Los Angeles County data. Los Angeles provides a unique scenario because the county verifies the cause of death for each COVID-19-related death reported on a death certificate. According to the Los Angeles County data, 7 people on average died of COVID-19 a day over the seven days preceding August 19, while the New York Times and the Centers for Disease Control and Prevention, which report deaths based on hospital data, reported an average of 12 deaths per day during the same period, a value nearly twice as high as Los Angeles County’s.
Therefore, currently reported COVID-19 deaths are an overestimate. When community COVID-19 positivity increases, deaths increase even if new infections are no longer likely to cause those deaths. By routinely testing every newly hospitalized patient without changing how we count COVID-19 deaths, we will never see a reduction in the number of COVID-19 deaths below the expected proportion based on community positivity.
Routinely testing every hospitalized patient for COVID-19 results in substantial financial costs. In addition, excess reported deaths likely exacerbate fear and COVID-19-related anxiety, contributing to the secondary crisis of mental health disorders. It also perpetuates other detrimental practices driven by a perception of crisis, such as testing of asymptomatic students in schools, which leads to significant lost learning, and excess testing among the workforce, which leads to lost productivity and staffing shortages.
In order to stop routinely testing all hospitalized patients for COVID-19, we must remove the perverse incentive of the Coronavirus Aid, Relief, and Economic Security Act, which provides hospitals an additional 20 percent compensation for Medicare patients diagnosed with COVID-19. We must also change how we count COVID-19 mortality. Review of each COVID-19-related death certificate, like Los Angeles County, requires time and money. Utilizing the already-established Centers for Disease Control’s COVID-19 hospital surveillance program for surveillance is appealing, however, it is not clear whether COVID-19-related deaths in that surveillance program are under rigorous review.
Regardless of strategy, we must end the recommended practice of adding COVID-19 as a contributing cause of death to every death certificate in all SARS-CoV-2 positive hospitalized patients. That practice is not only meaningless but also harmful.
Lao-Tzu Allan-Blitz, MD is the chief resident physician, Howard Hyatt Global Health Equities Residency, at Brigham and Women’s Hospital. Jeffrey D. Klausner, MD, MPH, is a USC professor of medicine and public health, a former Centers for Disease Control and Prevention medical officer and a former San Francisco city and county deputy health officer.