Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area

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Salient features:

This article focuses on :

  • Objective
  • Methods
  • Results
  • Outcomes for Patients Who Were Discharged or Died
  • Outcomes by Age and Risk Factors
  • Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use
  • Discussion
  • Limitations
  • Conclusion

Detailed summary:

Objective :

To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system.

Methods :

  • The study was conducted at hospitals in Northwell Health, New York,
  • The hospital review board approved the case series as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent.
  • All consecutive patients confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample were included.
  • Patients were admitted to any of 12 Northwell Health acute care hospitals between March 1, 2020, and April 4, 2020, inclusive of those dates.
  • Clinical outcomes were monitored until April 4, 2020.
  • Data were collected from the enterprise electronic health record (Sunrise Clinical Manager; Allscripts) reporting database, and all analyses were performed using version 3.5.2 of the R programming language.
  • Repeat tests were performed on inpatients during hospitalization shortly after initial test results were available if there was a high clinical pretest probability of COVID-19 or if the initial negative test result had been judged likely to be a false-negative due to poor sample collection.
  • Transfers from one in-system hospital to another were merged and considered as a single visit..
  • For patients with a readmission during the study period, data from the first admission are presented.
  • Data collected included patient demographic information, comorbidities, home medications, triage vitals, initial laboratory tests, initial electrocardiogram results, diagnoses during the hospital course, inpatient medications, treatments (including invasive mechanical ventilation and kidney replacement therapy), and outcomes (including length of stay, discharge, readmission, and mortality).
  • All clinical outcomes were presented for patients who completed their hospital course at study end (discharged alive or dead).
  • Clinical outcomes available for those in hospital at the study end point are presented, including invasive mechanical ventilation, ICU care, kidney replacement therapy, and length of stay in hospital.
  • Home medications were reported based on the admission medication reconciliation by the inpatient-accepting physician because this is the most reliable record of home medications.
  • Final reconciliation has been delayed until discharge during the current pandemic. Home medications are therefore presented only for patients who have completed their hospital course to ensure accuracy.
  • Race and ethnicity data were collected by self-report in prespecified fixed categories.
  • Initial laboratory testing was defined as the first test results available, typically within 24 hours of admission. For initial laboratory testing and clinical studies for which not all patients had values, percentages of total patients with completed tests are shown.
  • The Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities and was used as a measure of total comorbidity burden.The lowest score of 0 corresponds to a 98% estimated 10-year survival rate. Increasing age in decades older than age 50 years and comorbidities, including congestive heart disease and cancer, increase the total score and decrease the estimated 10-year survival. A total of 16 comorbidities are included. A score of 7 points and above corresponds to a 0% estimated 10-year survival rate. Acute kidney injury was identified as an increase in serum creatinine by 0.3 mg/dL or more (≥26.5 μmol/L) within 48 hours or an increase in serum creatinine to 1.5 times or more baseline within the prior 7 days compared with the preceding 1 year of data in acute care medical records.

Results:

  • A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female).
  • The median time to obtain polymerase chain reaction testing results was 15.4 hours.
  • The most common comorbidities were hypertension (3026, 56.6%), obesity (1737, 41.7%), and diabetes (1808, 33.8%).
  • The median score on the Charlson Comorbidity Index was 4 points (IQR, 2-6), which corresponds to a 53% estimated 10-year survival and reflects a significant comorbidity burden for these patients.
  • At triage, 1734 patients (30.7%) were febrile, 986 (17.3%) had a respiratory rate greater than 24 breaths/minute, and 1584 (27.8%) received supplemental oxygen.
  • The first test for COVID-19 was positive in 5517 patients (98.1%), while 13 patients (1.9%) had a negative first test and positive repeat test.
  • The rate of co-infection with another respiratory virus for those tested was 2.1% (42/1996).
  • Discharge disposition by 10-year age intervals of all 5700 study patients presented the length of stay for those who died, were discharged alive, and remained in hospital.
  • Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1). Mortality was 0% (0/20) for male and female patients younger than 20 years. Mortality rates were higher for male compared with female patients at every 10-year age interval older than 20 years.
  • Outcomes for Patients Who Were Discharged or Died
  • Among the 2634 patients who were discharged or had died at the study end point, during hospitalization, 373 were treated in the ICU, 320 received invasive mechanical ventilation, 81 were treated with kidney replacement therapy, and 553 died.
  • Mortality for those who received mechanical ventilation was 88.1%.
  • Mortality rates for those who received mechanical ventilation in the 18-to-65 and older-than-65 age groups were 76.4% and 97.2%, respectively.
  • Mortality rates for those in the 18-to-65 and older-than-65 age groups who did not receive mechanical ventilation were 19.8% and 26.6%, respectively.
  • The overall length of stay was 4.1 days. The median postdischarge follow-up time was 4.4 days.
  • A total of 45 patients were readmitted during the study period. The median time to readmission was 3 days.
  • Of the patients who were discharged or had died at the study end point, 436 were younger than age 50 with a score of 0 on the Charlson Comorbidity Index, of whom 9 died.
  • Outcomes by Age and Risk Factors
  • For both patients discharged alive and those who died, the percentage of patients who were treated in the ICU or received invasive mechanical ventilation was increased for the 18-to-65 age group compared with the older-than-65 years age group.
  • For patients discharged alive, the lowest absolute lymphocyte count during hospital course was lower for progressively older age groups.
  • For patients discharged alive, the readmission rates and the percentage of patients discharged to a facility (such as a nursing home or rehabilitation), as opposed to home, increased for progressively older age groups.
  • Of the patients who died, those with diabetes were more likely to have received invasive mechanical ventilation or care in the ICU compared with those who did not have diabetes.
  • Of the patients who died, those with hypertension were less likely to have received invasive mechanical ventilation or care in the ICU compared with those without hypertension.
  • The percentage of patients who developed acute kidney injury was increased in the subgroups with diabetes compared with subgroups without those conditions.
  • Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use
  • Home medication reconciliation information was available for 2411 of the 2634 patients who were discharged or who died by the study end.
  • Of these 2411 patients, 189 were taking an angiotensin-converting enzyme inhibitor at home and 267 were taking an angiotensin II receptor blocker  at home.
  • The median number of total home medications was 3.
  • Of the patients taking an ACEi at home, 91 continued taking an ACEi while in the hospital and the remainder discontinued this type of medication during their hospital visit.
  • Of the patients taking an ARB at home, 136 continued taking an ARB while in the hospital and the remainder discontinued taking this type of medication during their hospital visit.
  • Of patients who were not prescribed an ACEi or ARB at home, 49 started treatment with an ACEi and 58 started treatment with an ARB during their hospitalization.
  • Mortality rates for patients with hypertension not taking an ACEi or ARB, taking an ACEi, and taking an ARB were 26.7%, 32.7%, and 30.6%, respectively

Discussion:

  • The study represents the first large case series of sequentially hospitalized patients with confirmed COVID-19 in the US.
  • Older persons, men, and those with pre-existing hypertension and/or diabetes were highly prevalent in this case series.
  • Mortality rates in this case series were significantly lower due to differences in thresholds for hospitalization.
  • This study reported mortality rates only for patients with definite outcomes (discharge or death), and longer-term study may find different mortality rates as different segments of the population are infected.
  • The findings of high mortality rates among ventilated patients are similar to smaller case series reports of critically ill patients in the US.
  • ACEi and ARBmedications can significantly increase mRNA expression ofcardiac angiotensin-converting enzyme 2 (ACE2),leading to adverse, protective, or biphasic effects of treatment with these medications.
  • However, this case series design cannot address the complexity of this question, and the results are unadjusted for known confounders, including age, sex, race, ethnicity, socioeconomic status indicators, and comorbidities such as diabetes, chronic kidney disease, and heart failure.
  • Limitations
  • The study population only included patients within the New York metropolitan area.
  • The data were collected from the electronic health record database. This precluded the level of detail possible with a manual medical record review.
  • The median postdischarge follow-up time was relatively brief at 4.4 days (IQR, 2.2-9.3).
  • Subgroup descriptive statistics were unadjusted for potential confounders.
  • Clinical outcome data were available for only 46.2% of admitted patients. The absence of data on patients who remained hospitalized at the final study date may have biased the findings, including the high mortality rate of patients who received mechanical ventilation older than age 65 years.

Conclusion :

This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.

Reference Link: https://jamanetwork.com/channels/health-forum/fullarticle/2765172?utm_campaign=articlePDF%26utm_medium%3darticlePDFlink%26utm_source%3darticlePDF%26utm_content%3djama.2020.6775

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