As Hawaii’s COVID-19 case counts have surged to triple the level seen since the start of the pandemic, state and local leaders have stressed that the focus should be not on case counts but hospitalization numbers when deciding whether to reinstate restrictions on businesses and gatherings, shut down in-person learning or continue indoor masking requirements.

Indeed, the pandemic landscape has shifted significantly with a greater proportion of the state’s population vaccinated and boosted, more natural immunity from prior surges, the availability of better treatment options for those who do fall sick and a new variant that is showing to be less deadly than previous strains.

But the state’s data on the number of COVID-19 patients in hospitals can be misleading when it comes to trying to deduce how sick people are getting during the omicron surge and to what degree they are straining hospital resources. That’s because the figure includes patients who tested positive for the coronavirus during inpatient screenings, but were admitted to the hospital for other reasons, such as a moped accident. Hawaii health care officials on Wednesday estimated that at least 20% of patients included in the state’s COVID-19 hospitalization numbers were admitted for other reasons.

Hawaii is not unique in lumping all the patients together, but there have been growing calls to parcel out the data so that policy decisions can be better informed.

Skewed data

Early on in the pandemic, hospitals throughout the country, including in Hawaii, began screening all inpatients for COVID-19 regardless of whether the virus was suspected.

But studies have shown that this can significantly inflate the number of patients suffering from moderate to severe illness.

A study published in May by researchers at the Stanford University School of Medicine analyzed COVID-19 data from Lucile Packard Children’s Hospital Stanford between May 2020 and February.

Its authors concluded that 45% of the pediatric patients were admitted for reasons unrelated to COVID-19, under­scoring the importance of distinguishing between patients who were admitted because of COVID-19 and those who tested positive during screening.

Another study released in September analyzed the medical records of approximately 48,000 COVID-19 hospital admissions at veterans hospitals across the country. The researchers from VA Boston Healthcare System and Tufts University found that 36% of patients admitted to hospitals between March 2020 and January 2021, before vaccinations were widely available, were asymptomatic or had mild symptoms. This proportion increased to 48% during the months of January to June 2021, after the vaccine rollout.

The authors concluded that health care officials should include disease severity when reporting their hospitalization numbers.

“As we look to shift from cases to hospitalizations as a metric to drive policy and assess level of risk to a community or state or country, we should refine the definition of hospitalization. Those patients who are there with rather than from COVID don’t belong in the metric,” Shira Doron, an infectious-disease physician and hospital epidemiologist at Tufts Medical Center and one of the study’s co-authors, told The Atlantic in September.

The VA study was completed prior to the omicron surge and it’s not clear how that variant is affecting COVID-19 hospitalization data nationally. But at hospitals run by the Los Angeles County Department of Health Services, roughly two-thirds of patients who have tested positive were admitted for something other than the coronavirus, the Los Angeles Times reported this week.

The ‘incidental’

The Healthcare Association of Hawaii, a trade group for the state’s hospitals, reports statewide hospitalization data to the Department of Health. The data is used on the state’s COVID-19 websites.

In September, HAH told the Honolulu Star-Advertiser that its pediatric data included children who were admitted because of COVID-19, as well as those who tested positive during screening. But the trade group didn’t respond to questions at the time about whether that was the case for all age groups.

The Star-Advertiser has struggled for months to get a clear answer about the data. DOH repeatedly referred the newspaper back to HAH, which didn’t respond to the Star-Advertiser’s questions until Wednesday.

The U.S. Department of Health and Human Services, which also keeps track of COVID-19 hospitalizations for states, also hasn’t responded to numerous inquiries from the Star-Advertiser over several months, seeking clarification about the data posted on its website.

But on Wednesday, Honolulu Mayor Rick Blangiardi told reporters during a press conference that the data was indeed aggregated, which he suggested was all the more reason for his hesitancy in issuing a slew of new restrictions.

“There’s a lot of shock and awe going on right now about case counts,” Blangiardi said. “They are not as relevant as the hospitalizations. And while they do matter … 20% of our hospitalizations are incidental. People are going to the hospital for other reasons, getting swabbed and then finding out that they have COVID, which they didn’t even know that they had.”

Hawaii Pacific Health CEO Ray Vara said that combining the patient count is important for consistency in data reporting.

“Does it cause inflation of the numbers? I guess I’d have to say, ‘Yes, it does,’” he said during the press conference. “But we think it is important to identify them for consistency reasons, as we’ve been reporting across the last couple of years.”

HAH President and CEO Hilton Raethel said it was important to include incidental cases in the COVID-19 hospitalization counts because the hospitals must treat these patients as infectious, which drains resources. However, he said it would be ideal if the data would distinguish patients with COVID, versus those hospitalized because of COVID-19. He said health care leaders are looking to refine the data.

COVID-19 hospitalization numbers also play a role as states compete for support from the Federal Emergency Management Agency. With other states reporting their hospitalization numbers the same way, Hawaii could be disadvantaged if it qualified its COVID-19 numbers to include only patients who were admitted because of the virus.

Hawaii currently is asking FEMA for 933 nurses and other health care staff for eight weeks to assist hospitals with the COVID-19 surge, said Raethel. That translates to $90 million in aid for the hospitals.

Raethel noted that if Hawaii reduced its number to include only patients admitted for COVID-19 that would make the state’s situation “look a whole lot better.”

“Now the reality is we are actually taking care of 214 patients regardless of whether they are being treated primarily for COVID or not,” he said. “It’s not that anyone is trying to game the system. We are just being consistent in what we have done from Day One and we are being consistent with what other hospitals are doing as well.”

Raethel said that obtaining the FEMA staff is particularly critical right now since about 1,000 front-line health care workers in Hawaii are out because they tested positive or were exposed to COVID-19.

The state’s hospitalization numbers are also expected to grow, with health care leaders not expecting the current surge to peak until mid-January.

Hawaii Department of Health officials reported 2,611 new coronavirus infections on Wednesday. The statewide test positivity rate stood at 17.8%. There were 25 COVID-19 patients admitted to intensive care units statewide and 13 patients were on ventilators, according to state data. Health care officials are urging residents to get booster shots.