{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T03:51:15Z","timestamp":1791258675722,"version":"4.1.0"},"reference-count":35,"publisher":"Wiley","issue":"9","license":[{"start":{"date-parts":[[2026,8,15]],"date-time":"2026-08-15T00:00:00Z","timestamp":1786752000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,8,15]],"date-time":"2026-08-15T00:00:00Z","timestamp":1786752000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Risk Analysis"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>Elevated healthcare strain during the COVID\u201019 pandemic increased patient mortality rates and prompted costly non\u2010pharmaceutical interventions. This work examines how the size of a hospital's service population, which can be expanded by linking hospitals through patient transfer networks, influences healthcare strain through two diversification mechanisms: (i) volatility dampening, which reduces the volatility of demand for healthcare resources by aggregating uncorrelated individual patient needs, and (ii) epidemic phase averaging, which flattens demand peaks by aggregating patients from asynchronous local epidemics. Using facility\u2010level intensive care unit (ICU) data across three COVID waves, we analyze how service population size affects the size of peaks in ICU occupancy, evaluate the two proposed mechanisms, and explore the health impacts of pooling through scenario simulations grounded in observed occupancy levels. We find that volatility dampening effects reduce variability in ICU occupancy at a rate proportional to the square root of population size, whereas the effectiveness of epidemic phase averaging is dependent on the transmission dynamics of the pathogen. Increasing service population size also reduces the frequency and magnitude of demand spikes, lowering the likelihood of costly short\u2010term interventions and increasing demand predictability. In the winter 2020 wave, our simulations find that randomly constructed local pools (2\u20136 hospitals) reduce COVID ICU mortality by a median of 2%\u20137%, with reductions exceeding 6%\u201318% in the top decile of outcomes. These findings suggest that coordinated patient transfer strategies could meaningfully reduce mortality and costs during future pandemics.<\/jats:p>","DOI":"10.1111\/risa.70329","type":"journal-article","created":{"date-parts":[[2026,8,15]],"date-time":"2026-08-15T10:40:56Z","timestamp":1786790456000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Hospital Capacity Pooling in Pandemics: Simulation\u2010Based Mortality Impacts and Diversification Mechanisms"],"prefix":"10.1111","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-7578-8484","authenticated-orcid":false,"given":"Francois","family":"Daudelin","sequence":"first","affiliation":[{"name":"Institute for Risk Management and Insurance Innovation, University of North Carolina  Chapel Hill, NC USA"},{"name":"Department of Environmental Sciences and Engineering, University of North Carolina  Chapel Hill, NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harrison B.","family":"Zeff","sequence":"additional","affiliation":[{"name":"Institute for Risk Management and Insurance Innovation, University of North Carolina  Chapel Hill, NC USA"},{"name":"Department of Environmental Sciences and Engineering, University of North Carolina  Chapel Hill, NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory W.","family":"Characklis","sequence":"additional","affiliation":[{"name":"Institute for Risk Management and Insurance Innovation, University of North Carolina  Chapel Hill, NC USA"},{"name":"Department of Environmental Sciences and Engineering, University of North Carolina  Chapel Hill, NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,8,15]]},"reference":[{"key":"e_1_2_9_2_1","doi-asserted-by":"publisher","DOI":"10.1111\/jocn.16620"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000004766"},{"key":"e_1_2_9_4_1","doi-asserted-by":"crossref","unstructured":"Boudourakis L. D. M.Silvestri S.Natsui et\u00a0al.2020.Using Interfacility Transfers To \u2018Level\u2010Load\u2019 Demand From Surging COVID\u201019 Patients: Lessons From NYC Health + Hospitals.Health Affairs Publishing.https:\/\/doi.org\/10.1377\/forefront.20200710.163676.","DOI":"10.1377\/forefront.20200710.163676"},{"key":"e_1_2_9_5_1","doi-asserted-by":"publisher","DOI":"10.1002\/9781394323104"},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.34266"},{"key":"e_1_2_9_7_1","volume-title":"Patient Safety and Quality: An Evidence\u2010Based Handbook for Nurses","author":"Carayon P.","year":"2008"},{"key":"e_1_2_9_8_1","unstructured":"CDC.2025.COVID\u201019 Vaccinations in the United States County | Data.Centers for Disease Control and Prevention.https:\/\/data.cdc.gov\/Vaccinations\/COVID\u201019\u2010Vaccinations\u2010in\u2010the\u2010United\u2010States\u2010County\/8xkx\u2010amqh\/about_data."},{"issue":"3","key":"e_1_2_9_9_1","first-page":"377","article-title":"Hospital Length of Stay Among COVID\u201019\u2010Positive Patients","volume":"7","author":"Chiam T.","year":"2021","journal-title":"Journal of Clinical and Translational Research"},{"key":"e_1_2_9_10_1","doi-asserted-by":"crossref","unstructured":"Coibion O. Y.Gorodnichenko andM.Weber.May 2020. \u201cThe Cost of the Covid\u201019 Crisis: Lockdowns Macroeconomic Expectations and Consumer Spending.\u201d Working Paper 27141.National Bureau of Economic Research.","DOI":"10.3386\/w27141"},{"key":"e_1_2_9_11_1","doi-asserted-by":"publisher","DOI":"10.1017\/S1049023X22001169"},{"key":"e_1_2_9_12_1","unstructured":"DHHS.2024.COVID\u201019 Reported Patient Impact and Hospital Capacity by Facility.HealthData.gov.https:\/\/healthdata.gov\/Hospital\/COVID\u201019\u2010Reported\u2010Patient\u2010Impact\u2010and\u2010Hospital\u2010Capa\/anag\u2010cw7u\/about_data."},{"key":"e_1_2_9_13_1","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph18020659"},{"key":"e_1_2_9_14_1","doi-asserted-by":"crossref","unstructured":"Franklin B. J. S. H.Mitchell L.Villarroel et\u00a0al.2023. \u201cState Capacity Coordination Centers to Facilitate Access to Acute Care: A National Survey and Analysis.\u201dNEJM Catalyst5 no.1.https:\/\/doi.org\/10.1056\/CAT.23.0205.","DOI":"10.1056\/CAT.23.0205"},{"key":"e_1_2_9_15_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.16645"},{"key":"e_1_2_9_16_1","doi-asserted-by":"publisher","DOI":"10.7326\/M21\u20101991"},{"key":"e_1_2_9_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.chest.2025.08.023"},{"key":"e_1_2_9_18_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00134\u2010021\u201006412\u20103"},{"key":"e_1_2_9_19_1","doi-asserted-by":"publisher","DOI":"10.1111\/anae.15680"},{"key":"e_1_2_9_20_1","doi-asserted-by":"publisher","DOI":"10.7326\/M21-1213"},{"key":"e_1_2_9_21_1","doi-asserted-by":"publisher","DOI":"10.1103\/PhysRevLett.86.2909"},{"key":"e_1_2_9_22_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijnurstu.2024.104830"},{"key":"e_1_2_9_23_1","doi-asserted-by":"publisher","DOI":"10.1093\/jtm\/taac037"},{"key":"e_1_2_9_24_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598\u2010021\u201004653\u20102"},{"key":"e_1_2_9_25_1","unstructured":"NC DHSS.2024.2024 State Medical Facilities Plan.North Carolina Department of Health and Human Services Division of Health Service Regulation."},{"key":"e_1_2_9_26_1","doi-asserted-by":"publisher","DOI":"10.7326\/M24\u20100869"},{"key":"e_1_2_9_27_1","unstructured":"New York State Department of Health.2023.New York State Department of Health Updates List of Impacted Hospitals and Regions Due to Limited Staffed Patient Bed Capacity as Determined by Executive Order.New York State Department of Health.https:\/\/www.health.ny.gov\/press\/releases\/2022\/2022\u201001\u201008_hospital_bed_capacity.htm."},{"key":"e_1_2_9_28_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.56174"},{"key":"e_1_2_9_29_1","doi-asserted-by":"publisher","DOI":"10.1007\/978-94-011-1378-6_1"},{"key":"e_1_2_9_30_1","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.2011656117"},{"key":"e_1_2_9_31_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-05975-z"},{"key":"e_1_2_9_32_1","unstructured":"U.S. Census Bureau.2025.American Community Survey 2015\u20132019 5\u2010Year Data Release.Census.gov.https:\/\/www.census.gov\/newsroom\/press\u2010kits\/2020\/acs\u20105\u2010year.html."},{"key":"e_1_2_9_33_1","doi-asserted-by":"publisher","DOI":"10.1097\/PTS.0000000000000916"},{"key":"e_1_2_9_34_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2022.01657"},{"key":"e_1_2_9_35_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp2114767"},{"key":"e_1_2_9_36_1","doi-asserted-by":"publisher","DOI":"10.1097\/CCM.0000000000005464"}],"container-title":["Risk Analysis"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/risa.70329","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/risa.70329","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/risa.70329","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T03:08:10Z","timestamp":1791256090000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/risa.70329"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,15]]},"references-count":35,"journal-issue":{"issue":"9","published-print":{"date-parts":[[2026,9]]}},"alternative-id":["10.1111\/risa.70329"],"URL":"https:\/\/doi.org\/10.1111\/risa.70329","archive":["Portico"],"relation":{},"ISSN":["0272-4332","1539-6924"],"issn-type":[{"value":"0272-4332","type":"print"},{"value":"1539-6924","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,15]]},"assertion":[{"value":"2025-08-20","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-27","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-15","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70329"}}