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Counting Covid: SF doctors worry widely used metrics are misleading in Omicron surge

Local health professionals are concerned that overall Covid hospitalization numbers now include many people who were admitted for other ailments or injuries and then happened to test positive for the coronavirus, thus giving a distorted picture of the Omicron wave.

Dr. Jeanne Noble, an associate professor of emergency medicine at UCSF, said 43% of all Covid patients admitted to the hospital were there for something else. Among pediatric patients the number is 70%. UCSF believes the distinction is important enough to separate out the patients who have been admitted “with” Covid versus “for” Covid in their own internal data dashboard.

The public should focus on those numbers too, she said. "When they see hospitalization rates go up, people aren't thinking, ‘Oh, wait a minute, that's a person with appendicitis who doesn't have a cough,’” Noble said. In part due to Omicron’s lower relative impact on the lower respiratory tract, Noble said she has not been forced to intubate any patient yet across the entire Omicron wave. 

Dr. Anil Makam, an assistant professor of medicine at UCSF who also works as a clinician at SF General Hospital, agreed that the current Omicron surge requires an emphasis on different metrics. 

Makam said the distinction between those hospitalized “with” or “for” Covid was previously used as a “dog whistle” by those trying to downplay the effect of the virus. During the current wave, however, it has become a useful tool to understand the severity and condition of the current surge.

“The ugly is that Omicron is way more infectious than Delta, which is why cases are skyrocketing. The bad is we are still seeing tragedy that is preventable, particularly with people who are unvaccinated,” Makam said. “The good of Omicron—and how I’m trying to change the conversation—is that not all hospitalizations with people who test positive for Covid are those who we’ve seen hospitalized traditionally during the pandemic.”

New York Gov. Kathy Hochul announced plans earlier this month to request that hospitals provide the number of patients who were admitted with severe Covid, essentially those in respiratory distress, as part of an effort to give residents a better picture of the severity of the current surge.

“I think looking at severe Covid is an excellent idea because it gets back to why we care about this,” Noble said. “We cared about this initially in 2020 because we saw ICUs be overwhelmed, and we worried explicitly about our number of ventilators. We have gone so far afield from that initial concern.”

John Swartzberg, an infectious disease expert at UC Berkeley, said at the minimum, there should be a categorization splitting people hospitalized either “with” or “for” Covid, but that dichotomy doesn’t tell the whole story. Overall case counts can still be important to understand the level of community spread and help people dial in their risk calculations, he said.

“This is a brand new virus, and we don’t have a lot of information about how it’s going to behave,” Swartzberg said, adding that overall hospitalizations still have a critical impact on hospital capacity. 

Makam said hospitalization numbers also include patients waiting to be discharged because of isolation requirements for those living in congregate care settings like shelters and nursing homes. 

He’s optimistic about the longer term, as long as nasty new variants don’t emerge.

“January is going to be rough because so many people are testing positive, but at the same time once we get through this crunch and when our healthcare system is better positioned with more throughput and capacity, we will have largely accomplished our goal of April 2020 where we can prevent or avert most severe illness and deaths,” Makam said.

He added this was the first time across the entire pandemic that he has felt confident enough to make that statement publicly. 

Noble also stressed that the increasing number of incidental Covid cases “is a really good news story that should be publicized alongside all of the really fearful reporting that focuses on overall case numbers. We just have so much attention to this constant drumbeat of case counts, and I do think it is inciting panic in our Bay Area population.”

Noble said an increased number of “worried well” patients were coming to the emergency room looking to be tested or worried about developing more intense Covid symptoms.

The majority of patients in the emergency department who test positive for Covid have minimal symptoms and are discharged relatively quickly, Noble said. She groups the remaining individuals into a few key categories. 

First are the most severe cases: patients who are admitted with Covid due to a serious respiratory illness, for example, and who need supplemental oxygen. These patients are mostly either unvaccinated or vaccinated with compromised immune systems, according to Noble.

Then there are the “incidental Covid” patients who are admitted for issues unrelated to respiratory illness like appendicitis or a hip fracture and happen to test positive as part of regular screening. 

The last group are in a gray area: admitted patients whose Covid diagnosis contributed to their overall condition or need to be in the hospital. Noble said UCSF’s data collection methodology generally errs on categorizing this group as being admitted for Covid.

"I think it was less confusing before we had vaccinations because we had a pretty even playing field, so if somebody was sick enough to be hospitalized with Covid, they generally needed oxygen,” Noble said. “But as testing became incredibly widespread and the case counts became really decoupled from serious illness, we just did not keep up with that transition in our metrics.”

Kevin Truong can be reached at