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Johnson DR, Ghosh D, Wagner BD, Carlton EJ. Did COVID-19 ICU patient mortality risk increase as Colorado hospitals filled? A retrospective cohort study. BMJ Open 2024; 14:e079022. [PMID: 38724053 PMCID: PMC11086500 DOI: 10.1136/bmjopen-2023-079022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES To assess whether increasing levels of hospital stress-measured by intensive care unit (ICU) bed occupancy (primary), ventilators in use and emergency department (ED) overflow-were associated with decreasing COVID-19 ICU patient survival in Colorado ICUs during the pre-Delta, Delta and Omicron variant eras. DESIGN A retrospective cohort study using discrete-time survival models, fit with generalised estimating equations. SETTING 34 hospital systems in Colorado, USA, with the highest patient volume ICUs during the COVID-19 pandemic. PARTICIPANTS 9196 non-paediatric SARS-CoV-2 patients in Colorado hospitals admitted once to an ICU between 1 August 2020 and 1 March 2022 and followed for 28 days. OUTCOME MEASURES Death or discharge to hospice. RESULTS For Delta-era COVID-19 ICU patients in Colorado, the odds of death were estimated to be 26% greater for patients exposed every day of their ICU admission to a facility experiencing its all-era 75th percentile ICU fullness or above, versus patients exposed for none of their days (OR: 1.26; 95% CI: 1.04 to 1.54; p=0.0102), adjusting for age, sex, length of ICU stay, vaccination status and hospital quality rating. For both Delta-era and Omicron-era patients, we also detected significantly increased mortality hazard associated with high ventilator utilisation rates and (in a subset of facilities) states of ED overflow. For pre-Delta-era patients, we estimated relatively null or even protective effects for the same fullness exposures, something which provides a meaningful contrast to previous studies that found increased hazards but were limited to pre-Delta study windows. CONCLUSIONS Overall, and especially during the Delta era (when most Colorado facilities were at their fullest), increasing exposure to a fuller hospital was associated with an increasing mortality hazard for COVID-19 ICU patients.
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Affiliation(s)
- David R Johnson
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Debashis Ghosh
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Elizabeth J Carlton
- Department of Environmental & Occupational Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Neupane M, De Jonge N, Angelo S, Sarzynski S, Sun J, Rochwerg B, Hick J, Mitchell SH, Warner S, Mancera A, Cooper D, Kadri SS. Measures and Impact of Caseload Surge During the COVID-19 Pandemic: A Systematic Review. Crit Care Med 2024:00003246-990000000-00312. [PMID: 38517234 DOI: 10.1097/ccm.0000000000006263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
OBJECTIVES COVID-19 pandemic surges strained hospitals globally. We performed a systematic review to examine measures of pandemic caseload surge and its impact on mortality of hospitalized patients. DATA SOURCES PubMed, Embase, and Web of Science. STUDY SELECTION English-language studies published between December 1, 2019, and November 22, 2023, which reported the association between pandemic "surge"-related measures and mortality in hospitalized patients. DATA EXTRACTION Three authors independently screened studies, extracted data, and assessed individual study risk of bias. We assessed measures of surge qualitatively across included studies. Given multidomain heterogeneity, we semiquantitatively aggregated surge-mortality associations. DATA SYNTHESIS Of 17,831 citations, we included 39 studies, 17 of which specifically described surge effects in ICU settings. The majority of studies were from high-income countries (n = 35 studies) and included patients with COVID-19 (n = 31). There were 37 different surge metrics which were mapped into four broad themes, incorporating caseloads either directly as unadjusted counts (n = 11), nested in occupancy (n = 14), including additional factors (e.g., resource needs, speed of occupancy; n = 10), or using indirect proxies (e.g., altered staffing ratios, alternative care settings; n = 4). Notwithstanding metric heterogeneity, 32 of 39 studies (82%) reported detrimental adjusted odds/hazard ratio for caseload surge-mortality outcomes, reporting point estimates of up to four-fold increased risk of mortality. This signal persisted among study subgroups categorized by publication year, patient types, clinical settings, and country income status. CONCLUSIONS Pandemic caseload surge was associated with lower survival across most studies regardless of jurisdiction, timing, and population. Markedly variable surge strain measures precluded meta-analysis and findings have uncertain generalizability to lower-middle-income countries (LMICs). These findings underscore the need for establishing a consensus surge metric that is sensitive to capturing harms in everyday fluctuations and future pandemics and is scalable to LMICs.
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Affiliation(s)
- Maniraj Neupane
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Nathaniel De Jonge
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Sahil Angelo
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sadia Sarzynski
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Junfeng Sun
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John Hick
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Steven H Mitchell
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Sarah Warner
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Alex Mancera
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Diane Cooper
- Office of Research Services, Division of Library Services, National Institutes of Health, Bethesda, MD
| | - Sameer S Kadri
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
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Jiang HJ, Henke RM, Fingar KR, Liang L, Agniel D. Mortality for Time-Sensitive Conditions at Urban vs Rural Hospitals During the COVID-19 Pandemic. JAMA Netw Open 2024; 7:e241838. [PMID: 38470419 PMCID: PMC10933716 DOI: 10.1001/jamanetworkopen.2024.1838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/06/2024] [Indexed: 03/13/2024] Open
Abstract
Importance COVID-19 pandemic-related disruptions to the health care system may have resulted in increased mortality for patients with time-sensitive conditions. Objective To examine whether in-hospital mortality in hospitalizations not related to COVID-19 (non-COVID-19 stays) for time-sensitive conditions changed during the pandemic and how it varied by hospital urban vs rural location. Design, Setting, and Participants This cohort study was an interrupted time-series analysis to assess in-hospital mortality during the COVID-19 pandemic (March 8, 2020, to December 31, 2021) compared with the prepandemic period (January 1, 2017, to March 7, 2020) overall, by month, and by community COVID-19 transmission level for adult discharges from 3813 US hospitals in the State Inpatient Databases for the Healthcare Cost and Utilization Project. Exposure The COVID-19 pandemic. Main Outcomes and Measures The main outcome measure was in-hospital mortality among non-COVID-19 stays for 6 time-sensitive medical conditions: acute myocardial infarction, hip fracture, gastrointestinal hemorrhage, pneumonia, sepsis, and stroke. Entropy weights were used to align patient characteristics in the 2 time periods by age, sex, and comorbidities. Results There were 18 601 925 hospitalizations; 50.3% of patients were male, 38.5% were aged 18 to 64 years, 45.0% were aged 65 to 84 years, and 16.4% were 85 years or older for the selected time-sensitive medical conditions from 2017 through 2021. The odds of in-hospital mortality for sepsis increased 27% from the prepandemic to the pandemic periods at urban hospitals (odds ratio [OR], 1.27; 95% CI, 1.25-1.29) and 35% at rural hospitals (OR, 1.35; 95% CI, 1.30-1.40). In-hospital mortality for pneumonia had similar increases at urban (OR, 1.48; 95% CI, 1.42-1.54) and rural (OR, 1.46; 95% CI, 1.36-1.57) hospitals. Increases in mortality for these 2 conditions showed a dose-response association with the community COVID-19 level (low vs high COVID-19 burden) for both rural (sepsis: 22% vs 54%; pneumonia: 30% vs 66%) and urban (sepsis: 16% vs 28%; pneumonia: 34% vs 61%) hospitals. The odds of mortality for acute myocardial infarction increased 9% (OR, 1.09; 95% CI, 1.06-1.12) at urban hospitals and was responsive to the community COVID-19 level. There were significant increases in mortality for hip fracture at rural hospitals (OR, 1.32; 95% CI, 1.14-1.53) and for gastrointestinal hemorrhage at urban hospitals (OR, 1.15; 95% CI, 1.09-1.21). No significant change was found in mortality for stroke overall. Conclusions and Relevance In this cohort study, in-hospital mortality for time-sensitive conditions increased during the COVID-19 pandemic. Mobilizing strategies tailored to the different needs of urban and rural hospitals may help reduce the likelihood of excess deaths during future public health crises.
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Affiliation(s)
- H. Joanna Jiang
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Rachel M. Henke
- Now with Lewin Group, Boston, Massachusetts
- IBM Watson Health, Santa Barbara, California
| | - Kathryn R. Fingar
- IBM Watson Health, Santa Barbara, California
- Now with Everytown for Gun Safety, New York, New York
| | - Lan Liang
- Agency for Healthcare Research and Quality, Rockville, Maryland
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Kamal M, Baudo M, Joseph J, Geng Y, Mohamed O, Rahouma M, Greenbaum U. Characteristics and Outcomes of Stem Cell Transplant Patients during the COVID-19 Era: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2024; 12:530. [PMID: 38470640 PMCID: PMC10931059 DOI: 10.3390/healthcare12050530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/14/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024] Open
Abstract
This systematic review and meta-analysis aims to identify the outcomes of stem cell transplant (SCT) patients during the COVID-19 era. Pooled event rates (PER) were calculated, and meta-regression was performed. A random effects model was utilized. In total, 36 eligible studies were included out of 290. The PER of COVID-19-related deaths and COVID-19-related hospital admissions were 21.1% and 55.2%, respectively. The PER of the use of hydroxychloroquine was 53.27%, of the receipt of immunosuppression it was 39.4%, and of the use of antivirals, antibiotics, and steroids it was 71.61%, 37.94%, and 18.46%, respectively. The PER of the time elapsed until COVID-19 infection after SCT of more than 6 months was 85.3%. The PER of fever, respiratory symptoms, and gastrointestinal symptoms were 70.9, 76.1, and 19.3%, respectively. The PER of acute and chronic GvHD were 40.2% and 60.9%, respectively. SCT patients are at a higher risk of severe COVID-19 infection and mortality. The use of dexamethasone improves the survival of hospitalized SCT patients with moderate to severe COVID-19 requiring supplemental oxygen or ventilation. The SCT patient group is a heterogeneous group with varying characteristics. The quality of reporting on these patients when infected with COVID-19 is not uniform and further prospective or registry studies are needed to better guide clinical care in this unique setting.
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Affiliation(s)
- Mona Kamal
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Massimo Baudo
- Department of Cardiac Surgery, Spedali Civili di Brescia, 25123 Brescia, Italy;
| | - Jacinth Joseph
- Hematology and Medical Oncology, University of Pittsburg Medical Center-Hillman Cancer Center, Altoona, PA 16601, USA
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Omnia Mohamed
- Department of Medical Oncology, NCI, Cairo 11796, Egypt;
| | - Mohamed Rahouma
- Surgical Oncology Department, National Cancer Institute, Cairo 12613, Egypt;
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY 10065, USA
| | - Uri Greenbaum
- Department of Hematology, Soroka University Medical Center, Beer Sheva 8410501, Israel;
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 8410501, Israel
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5
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Murosko D, Passarella M, Handley SC, Burris HH, Lorch SA. Inter-hospital Variation in COVID-19 Era Pediatric Hospitalizations by Age Group and Diagnosis. Hosp Pediatr 2023; 13:e285-e291. [PMID: 37675486 DOI: 10.1542/hpeds.2023-007287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
BACKGROUND Mitigation strategies and public responses to coronavirus disease 2019 (COVID-19) varied geographically and may have differentially affected burden of pediatric disease and hospitalization practices. We aimed to quantify hospital-specific variation in hospitalizations during the COVID-19 era. METHODS Using Pediatric Health Information Systems data from 44 Children's Hospitals, this retrospective multicenter analysis compared hospitalizations of children (1 day-17 years) from the COVID-19 era (March 1, 2020-June 30, 2021) to prepandemic (January 1, 2017-December 31, 2019). Variation in the magnitude of hospital-specific decline between eras was determined using coefficients of variation (CV). Spearman's test was used to assess correlation of variation with community and hospital factors. RESULTS The COVID-19 era decline in hospitalizations varied between hospitals (CV 0.41) and was moderately correlated with declines in respiratory infection hospitalizations (r = 0.69, P < .001). There was no correlation with community or hospital factors. COVID-19 era changes in hospitalizations for mental health conditions varied widely between centers (CV 2.58). Overall, 22.7% of hospitals saw increased admissions for adolescents, and 29.5% saw increases for newborns 1 to 14 days, representing significant center-specific variation (CV 2.30 for adolescents and 1.98 for newborns). CONCLUSIONS Pandemic-era change in hospitalizations varied across institutions, partially because of hospital-specific changes in respiratory infections. Residual variation exists for mental health conditions and in groups least likely to be admitted for respiratory infections, suggesting that noninfectious conditions may be differentially and uniquely affected by local policies and hospital-specific practices enacted during the COVID-19 era.
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Affiliation(s)
- Daria Murosko
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Molly Passarella
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sara C Handley
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Heather H Burris
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Scott A Lorch
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
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6
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Mazzeffi M, Curley J, Gallo P, Stombaugh DK, Roach J, Lunardi N, Yount K, Thiele R, Glance L, Naik B. Variation in Hospitalization Costs, Charges, and Lengths of Hospital Stay for Coronavirus Disease 2019 Patients Treated With Venovenous Extracorporeal Membrane Oxygenation in the United States: A Cohort Study. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00237-9. [PMID: 37127521 PMCID: PMC10079589 DOI: 10.1053/j.jvca.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/16/2023] [Accepted: 04/02/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES The aim was to characterize hospitalization costs, charges, and lengths of hospital stay for COVID-19 patients treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) in the United States during 2020. Secondarily, differences in hospitalization costs, charges, and lengths of hospital stay were explored based on hospital-level factors. DESIGN Retrospective cohort study. SETTING Multiple hospitals in the United States. PARTICIPANTS Adult patients with COVID-19 who were on VV ECMO in 2020 and had data in the national inpatient sample. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics and baseline comorbidities were recorded for patients. Primary study outcomes were hospitalization costs, charges, and lengths of hospital stay. Study outcomes were compared after stratification by hospital region, bed size, and for-profit status. The median hospitalization cost for the 3,315-patient weighted cohort was $200,300 ($99,623, $338,062). Median hospitalization charges were $870,513 ($438,228, $1,553,157), and the median length of hospital stay was 30 days (17, 46). Survival to discharge was 54.4% for all patients in the cohort. Median hospitalization cost differed by region (p = 0.01), bed size (p < 0.001), and for-profit status (p = 0.02). Median hospitalization charges also differed by region (p = 0.04), bed size (p = 0.002), and for-profit status (p < 0.001). Length of hospital stay differed by region (p = 0.03) and bed size (p < 0.001), but not for-profit status (p = 0.40). Hospitalization costs were the lowest, and charges were highest in private-for-profit hospitals. Large hospitals also had higher costs, charges, and hospital stay lengths than small hospitals. CONCLUSIONS In this retrospective cohort study, hospitalization costs and charges for patients with COVID-19 on VV ECMO were found to be substantial but similar to what has been reported previously for patients without COVID-19 on VV ECMO. Significant variation was observed in costs, charges, and lengths of hospital stay based on hospital-level factors.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia.
| | - Jonathan Curley
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Paul Gallo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - D Keegan Stombaugh
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Joshua Roach
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Nadia Lunardi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Kenan Yount
- Department of Surgery, Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, Virginia
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Laurent Glance
- Department of Anesthesiology, University of Rochester, Rochester, New York
| | - Bhiken Naik
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
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Fischer SH, Landis RK, Acosta JD, Faherty LJ. Changes in Poison Center Calls for Intentional Exposure During Public Health Emergencies: COVID-19 and Winter Storm Uri in Dallas County, Texas. Disaster Med Public Health Prep 2023; 17:e361. [PMID: 36942743 DOI: 10.1017/dmp.2023.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE This study aimed to: (1) explore changes in the volume of calls to poison control centers (PCs) for intentional exposures (IEs) in Dallas County, Texas, overall and by gender and age, and (2) examine the association between 2 different public health emergencies (PHEs) and changes in IE call volume. METHODS PCs categorize calls they receive by intentionality of the exposure, based on information from the caller. We analyzed data on PC calls categorized as intentional in Dallas County, Texas, from March 2019 - April 2021. This period includes the COVID-19 pandemic declaration (March 2020), a surge in COVID-19 cases (July 2020), and Winter Storm Uri (February 2021). Changes in IE call volume (overall and by age and gender), were explored, and interrupted time series analysis was used to examine call volume changes after PHE onset. RESULTS The summer surge in COVID-19 cases was associated with 1.9 additional IE calls/day (95% CI 0.7 to 3.1), in the context of a baseline unadjusted mean of 6.2 calls per day (unadjusted) before November 3, 2020. Neither the pandemic declaration nor Winter Storm Uri was significantly associated with changes in call volume. Women, on average, made 1.2 more calls per day compared to men during the study period. IE calls for youth increased after the pandemic declaration, closing the longstanding gap between adults and youth by early 2021. CONCLUSIONS Changes in IE call volume in Dallas County varied by gender and age. Calls increased during the local COVID-19 surge. Population-level behavioral health may be associated with local crisis severity.
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Affiliation(s)
| | | | | | - Laura J Faherty
- RAND Corporation, Boston, MA
- Department of Pediatrics, Maine Medical Center, Portland, ME
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA
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8
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Lichtenstein BJ, Smith T, Smith B, Sitzer M, Mahida D, Exley D. The impact of key secular trends during the first three waves the COVID-19 pandemic. Ann Epidemiol 2022; 76:158-164. [PMID: 35779708 PMCID: PMC9239923 DOI: 10.1016/j.annepidem.2022.06.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Patient age, comorbidity burden, and disease severity at presentation are the major factors associated with surviving COVID-19. Hospital-level factors including ICU occupancy may confer additional risk to individual patients, particularly at times of maximal stress on healthcare systems. The interaction of patient- and hospital-level factors over time during pandemic disease remains an area of active exploration. OBJECTIVE To determine the impact of patient and hospital risk factors during episodic surges, characterize severity distribution between waves, and evaluate patient-level impact of ICU capacity on COVID-19 survivorship. DESIGN Retrospective cohort study. SETTING Four acute care hospitals within an integrated healthcare network in San Diego, California. PARTICIPANTS All patients (18+ y.o.) admitted with a positive PCR test for SARS-CoV-2 or ICD-10 code for COVID-19 from March 1, 2020 through June 30, 2021. MAIN OUTCOME(S) AND MEASURE(S) Patient survivorship and length of stay. RESULTS Six thousand eight hundred fifty-one patients were evaluated in this large cohort series. Patient level factors associated with mortality included: severity at admission (WHO Clinical Progression Score [WCPS]), age, gender, BMI, marital status, language preference, Elixhauser score, elevated laboratory (d-dimer, ferritin, LDH) or lower absolute lymphocyte count. When adjusting for patient age alone, survivorship during surges was also inversely associated with ICU occupancy, though this correlation was not present when adjusted for patient-level factors. CONCLUSIONS AND RELEVANCE Patient age, comorbidity burden, and severity at the time of presentation are the major factors associated with surviving COVID-19. Hospital-level factors including ICU occupancy may confer additional risk to individual patients, particularly at times of maximal stress on healthcare systems.
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Affiliation(s)
- Brian J. Lichtenstein
- Sharp HealthCare, San Diego, CA, USA,Corresponding author: Sharp HealthCare, Department of Medicine, 2929 Health Center Drive, San Diego, CA 92123. Tel.: 858-499-2770
| | | | | | | | | | - Dan Exley
- Sharp HealthCare, San Diego, CA, USA
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9
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Fatality assessment and variant risk monitoring for COVID-19 using three new hospital occupancy related metrics. EBioMedicine 2022; 83:104225. [PMID: 36030648 PMCID: PMC9415498 DOI: 10.1016/j.ebiom.2022.104225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Though case fatality rate (CFR) is widely used to reflect COVID-19 fatality risk, its use is limited by large temporal and spatial variation. Hospital mortality rate (HMR) is also used to assess the severity of COVID-19, but HMR data is not directly available globally. Alternative metrics are needed for COVID-19 severity and fatality assessment. METHODS We introduce new metrics for COVID-19 fatality risk measurements/monitoring and a new mathematical model to estimate average hospital length of stay for deaths (Ldead) and discharges (Ldis). Multiple data sources were used for our analyses. FINDINGS We propose three, new metrics: hospital occupancy mortality rate (HOMR), ratio of total deaths to hospital occupancy (TDHOR), and ratio of hospital occupancy to cases (HOCR), for dynamic assessment of COVID-19 fatality risk. Estimated Ldead and Ldis for 501,079 COVID-19 hospitalizations in 34 US states between 7 August 2020 and 1 March 2021 were 18·2(95%CI:17·9-18·5) and 14·0(95%CI:13·9-14·0) days, respectively. We found the dramatic changes in COVID-19 CFR observed in 27 countries during early stages of the pandemic were mostly caused by undiagnosed cases. Compared to the first week of November 2021, the week mean HOCRs (mimics hospitalization-to-case ratio) for Omicron variant (58·6% of US new cases as of 25 December 2021) decreased 65·16% in the US as of 16 January 2022. INTERPRETATION The new and reliable measurements described here could be useful for COVID-19 fatality risk and variant-associated risk monitoring. FUNDING No specific funding was associated with the present study.
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10
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Morrell ED, Bhatraju PK, Sathe NA, Lawson J, Mabrey L, Holton SE, Presnell SR, Wiedeman A, Acosta-Vega C, Mitchem MA, Liu T, Chai XY, Sahi S, Brager C, Orlov M, Sakr SS, Sader A, Lum DM, Koetje N, Garay A, Barnes E, Cromer G, Bray MK, Pipavath S, Fink SL, Evans L, Long SA, West TE, Wurfel MM, Mikacenic C. Chemokines, soluble PD-L1, and immune cell hyporesponsiveness are distinct features of SARS-CoV-2 critical illness. Am J Physiol Lung Cell Mol Physiol 2022; 323:L14-L26. [PMID: 35608267 PMCID: PMC9208434 DOI: 10.1152/ajplung.00049.2022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Critically ill patients manifest many of the same immune features seen in coronavirus disease 2019 (COVID-19), including both "cytokine storm" and "immune suppression." However, direct comparisons of molecular and cellular profiles between contemporaneously enrolled critically ill patients with and without severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are limited. We sought to identify immune signatures specifically enriched in critically ill patients with COVID-19 compared with patients without COVID-19. We enrolled a multisite prospective cohort of patients admitted under suspicion for COVID-19, who were then determined to be SARS-CoV-2-positive (n = 204) or -negative (n = 122). SARS-CoV-2-positive patients had higher plasma levels of CXCL10, sPD-L1, IFN-γ, CCL26, C-reactive protein (CRP), and TNF-α relative to SARS-CoV-2-negative patients adjusting for demographics and severity of illness (Bonferroni P value < 0.05). In contrast, the levels of IL-6, IL-8, IL-10, and IL-17A were not significantly different between the two groups. In SARS-CoV-2-positive patients, higher plasma levels of sPD-L1 and TNF-α were associated with fewer ventilator-free days (VFDs) and higher mortality rates (Bonferroni P value < 0.05). Lymphocyte chemoattractants such as CCL17 were associated with more severe respiratory failure in SARS-CoV-2-positive patients, but less severe respiratory failure in SARS-CoV-2-negative patients (P value for interaction < 0.01). Circulating T cells and monocytes from SARS-CoV-2-positive subjects were hyporesponsive to in vitro stimulation compared with SARS-CoV-2-negative subjects. Critically ill SARS-CoV-2-positive patients exhibit an immune signature of high interferon-induced lymphocyte chemoattractants (e.g., CXCL10 and CCL17) and immune cell hyporesponsiveness when directly compared with SARS-CoV-2-negative patients. This suggests a specific role for T-cell migration coupled with an immune-checkpoint regulatory response in COVID-19-related critical illness.
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Affiliation(s)
- Eric D Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Neha A Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Jonathan Lawson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Linzee Mabrey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Sarah E Holton
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Scott R Presnell
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Alice Wiedeman
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | | | - Mallorie A Mitchem
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Ted Liu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Xin-Ya Chai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Sharon Sahi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Carolyn Brager
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Marika Orlov
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
| | - Sana S Sakr
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Anthony Sader
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Dawn M Lum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Neall Koetje
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Ashley Garay
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Elizabeth Barnes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Gail Cromer
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Mary K Bray
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Sudhakar Pipavath
- Department of Radiology, University of Washington, Seattle, Washington
| | - Susan L Fink
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - S Alice Long
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - T Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Carmen Mikacenic
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
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11
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Bottle A, Faitna P, Brett S, Aylin P. Factors associated with, and variations in, COVID-19 hospital death rates in England's first two waves: observational study. BMJ Open 2022; 12:e060251. [PMID: 35772812 PMCID: PMC9247323 DOI: 10.1136/bmjopen-2021-060251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To assess patient-level and hospital-level predictors of death and variation in death rates following admission for COVID-19 in England's first two waves after accounting for random variation. To quantify the correlation between hospitals' first and second wave death rates. DESIGN Observational study using administrative data. SETTING Acute non-specialist hospitals in England. PARTICIPANTS All patients admitted with a primary diagnosis of COVID-19. PRIMARY AND SECONDARY OUTCOMES In-hospital death. RESULTS Hospital Episode Statistics (HES) data were extracted for all acute hospitals in England for COVID-19 admissions from March 2020 to March 2021. In wave 1 (March to July 2020), there were 74 484 admissions and 21 883 deaths (crude rate 29.4%); in wave 2 (August 2020 to March 2021), there were 165 642 admissions and 36 040 deaths (21.8%). Wave 2 patients were younger, with more hypertension and obesity but lower rates of other comorbidities. Mortality improved for all ages; in wave 2, it peaked in December 2020 at 24.2% (lower than wave 1's peak) but halved by March 2021. In multiple multilevel modelling combining HES with hospital-level data from Situational Reports, wave 2 and wave 1 variables significantly associated with death were mostly the same. The median odds ratio for wave 1 was just 1.05 and for wave 2 was 1.07. At 99.8% control limits, 3% of hospitals were high and 7% were low funnel plot outliers in wave 1; these figures were 9% and 12% for wave 2. Four hospitals were (low) outliers in both waves. The correlation between hospitals' adjusted mortality rates between waves was 0.45 (p<0.0001). Length of stay was similar in each wave. CONCLUSIONS England's first two COVID-19 waves were similar regarding predictors and moderate interhospital variation. Despite the challenges, variation in death rates and length of stay between hospitals was modest and might be accounted for by unobserved patient factors.
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Affiliation(s)
- Alex Bottle
- School of Public Health, Imperial College London, London, UK
| | - Puji Faitna
- School of Public Health, Imperial College London, London, UK
| | - Stephen Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
- Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - Paul Aylin
- School of Public Health, Imperial College London, London, UK
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12
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Xia Y, Ma H, Buckeridge DL, Brisson M, Sander B, Chan A, Verma A, Ganser I, Kronfli N, Mishra S, Maheu-Giroux M. Mortality trends and lengths of stay among hospitalized COVID-19 patients in Ontario and Québec (Canada): a population-based cohort study of the first three epidemic waves. Int J Infect Dis 2022; 121:1-10. [PMID: 35477050 PMCID: PMC9040412 DOI: 10.1016/j.ijid.2022.04.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/08/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022] Open
Abstract
Background Epidemics of COVID-19 strained hospital resources. We describe temporal trends in mortality risk and length of stays in hospital and intensive care units (ICUs) among patients with COVID-19 hospitalized through the first three epidemic waves in Canada. Methods We used population-based provincial hospitalization data from the epicenters of Canada's epidemics (Ontario and Québec). Adjusted estimates were obtained using marginal standardization of logistic regression models, accounting for patient-level and hospital-level determinants. Results Using all hospitalizations from Ontario (N = 26,538) and Québec (N = 23,857), we found that unadjusted in-hospital mortality risks peaked at 31% in the first wave and was lowest at the end of the third wave at 6–7%. This general trend remained after adjustments. The odds of in-hospital mortality in the highest patient load quintile were 1.2-fold (95% CI: 1.0–1.4; Ontario) and 1.6-fold (95% CI: 1.3–1.9; Québec) that of the lowest quintile. Mean hospital and ICU length of stays decreased over time but ICU stays were consistently higher in Ontario than Québec. Conclusions In-hospital mortality risks and length of ICU stays declined over time despite changing patient demographics. Continuous population-based monitoring of patient outcomes in an evolving epidemic is necessary for health system preparedness and response.
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Affiliation(s)
- Yiqing Xia
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Huiting Ma
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - David L Buckeridge
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Marc Brisson
- Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Beate Sander
- Management and Evaluation (IHPME), Dalla Lana School of Public Health, Institute of Health Policy, University of Toronto; Toronto Health Economics and Technology Assessment (THETA) collaborative, University Health Network; Public Health Ontario, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Adrienne Chan
- Management and Evaluation (IHPME), Dalla Lana School of Public Health, Institute of Health Policy, University of Toronto; Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aman Verma
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Iris Ganser
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Nadine Kronfli
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montréal, QC, Canada; Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University Health Centre, Montréal, QC, Canada
| | - Sharmistha Mishra
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Management and Evaluation (IHPME), Dalla Lana School of Public Health, Institute of Health Policy, University of Toronto; Institute of Medical Sciences, University of Toronto
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada.
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13
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Grosicki GJ, Bunsawat K, Jeong S, Robinson AT. Racial and ethnic disparities in cardiometabolic disease and COVID-19 outcomes in White, Black/African American, and Latinx populations: Social determinants of health. Prog Cardiovasc Dis 2022; 71:4-10. [PMID: 35490870 PMCID: PMC9047517 DOI: 10.1016/j.pcad.2022.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 04/24/2022] [Indexed: 02/07/2023]
Abstract
Racial and ethnic-related health disparities in the United States have been intensified by the greater burden of Coronavirus Disease 2019 (COVID-19) in racial and ethnic minority populations. Compared to non-Hispanic White individuals, non-Hispanic Black and Hispanic/Latinx individuals infected by COVID-19 are at greater risk for hospitalization, intensive care unit admission, and death. There are several factors that may contribute to disparities in COVID-19-related severity and outcomes in these minority populations, including the greater burden of cardiovascular and metabolic diseases as discussed in our companion review article. Social determinants of health are a critical, yet often overlooked, contributor to racial and ethnic-related health disparities in non-Hispanic Black and Hispanic/Latinx individuals relative to non-Hispanic White individuals. Thus, the purpose of this review is to focus on the essential role of social factors in contributing to health disparities in chronic diseases and COVID-19 outcomes in minority populations. Herein, we begin by focusing on structural racism as a social determinant of health at the societal level that contributes to health disparities through downstream social level (e.g., occupation and residential conditions) and individual level health behaviors (e.g., nutrition, physical activity, and sleep). Lastly, we conclude with a discussion of practical applications and recommendations for future research and public health efforts that seek to reduce health disparities and overall disease burden.
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Affiliation(s)
- Gregory J Grosicki
- Department of Health Sciences and Kinesiology, Biodynamics and Human Performance Center, Georgia Southern University (Armstrong Campus), Savannah, GA 31419, USA
| | - Kanokwan Bunsawat
- Department of Internal Medicine, Division of Geriatrics, University of Utah, Salt Lake City, UT 84132, USA; Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA
| | - Soolim Jeong
- Neurovascular Physiology Laboratory, School of Kinesiology, Auburn University, Auburn, AL 36849, USA
| | - Austin T Robinson
- Neurovascular Physiology Laboratory, School of Kinesiology, Auburn University, Auburn, AL 36849, USA.
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14
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Ebinger JE, Lan R, Driver M, Sun N, Botting P, Park E, Davis T, Minissian MB, Coleman B, Riggs R, Roberts P, Cheng S. Seasonal COVID-19 surge related hospital volumes and case fatality rates. BMC Infect Dis 2022; 22:178. [PMID: 35197000 PMCID: PMC8864601 DOI: 10.1186/s12879-022-07139-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/09/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Seasonal and regional surges in COVID-19 have imposed substantial strain on healthcare systems. Whereas sharp inclines in hospital volume were accompanied by overt increases in case fatality rates during the very early phases of the pandemic, the relative impact during later phases of the pandemic are less clear. We sought to characterize how the 2020 winter surge in COVID-19 volumes impacted case fatality in an adequately-resourced health system. METHODS We performed a retrospective cohort study of all adult diagnosed with COVID-19 in a large academic healthcare system between August 25, 2020 to May 8, 2021, using multivariable logistic regression to examine case fatality rates across 3 sequential time periods around the 2020 winter surge: pre-surge, surge, and post-surge. Subgroup analyses of patients admitted to the hospital and those receiving ICU-level care were also performed. Additionally, we used multivariable logistic regression to examine risk factors for mortality during the surge period. RESULTS We studied 7388 patients (aged 52.8 ± 19.6 years, 48% male) who received outpatient or inpatient care for COVID-19 during the study period. Patients treated during surge (N = 6372) compared to the pre-surge (N = 536) period had 2.64 greater odds (95% CI 1.46-5.27) of mortality after adjusting for sociodemographic and clinical factors. Adjusted mortality risk returned to pre-surge levels during the post-surge period. Notably, first-encounter patient-level measures of illness severity appeared higher during surge compared to non-surge periods. CONCLUSIONS We observed excess mortality risk during a recent winter COVID-19 surge that was not explained by conventional risk factors or easily measurable variables, although recovered rapidly in the setting of targeted facility resources. These findings point to how complex interrelations of population- and patient-level pandemic factors can profoundly augment health system strain and drive dynamic, if short-lived, changes in outcomes.
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Affiliation(s)
- Joseph E. Ebinger
- grid.50956.3f0000 0001 2152 9905Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA USA ,grid.50956.3f0000 0001 2152 9905Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Roy Lan
- grid.267301.10000 0004 0386 9246College of Medicine, University of Tennessee Health Science Center, Memphis, TN USA
| | - Matthew Driver
- grid.50956.3f0000 0001 2152 9905Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Nancy Sun
- grid.50956.3f0000 0001 2152 9905Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Patrick Botting
- grid.50956.3f0000 0001 2152 9905Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Eunice Park
- grid.50956.3f0000 0001 2152 9905Enterprise Data Intelligence, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Tod Davis
- grid.50956.3f0000 0001 2152 9905Enterprise Data Intelligence, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Margo B. Minissian
- grid.50956.3f0000 0001 2152 9905Brawerman Nursing Institute and Nursing Research Department, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Bernice Coleman
- grid.50956.3f0000 0001 2152 9905Brawerman Nursing Institute and Nursing Research Department, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Richard Riggs
- grid.50956.3f0000 0001 2152 9905Department of Medical Affairs, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Pamela Roberts
- grid.50956.3f0000 0001 2152 9905Department of Medical Affairs, Cedars-Sinai Medical Center, Los Angeles, CA USA ,grid.50956.3f0000 0001 2152 9905Department of Biomedical Sciences, Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Susan Cheng
- grid.50956.3f0000 0001 2152 9905Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA USA ,grid.50956.3f0000 0001 2152 9905Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA USA
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15
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Maves RC, Richard SA, Lindholm DA, Epsi N, Larson DT, Conlon C, Everson K, Lis S, Blair PW, Chi S, Ganesan A, Pollett S, Burgess TH, Agan BK, Colombo RE, Colombo CJ. Predictive Value of an Age-Based Modification of the National Early Warning System in Hospitalized Patients With COVID-19. Open Forum Infect Dis 2021; 8:ofab421. [PMID: 34877361 PMCID: PMC8643671 DOI: 10.1093/ofid/ofab421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Early recognition of high-risk patients with coronavirus disease 2019 (COVID-19) may improve outcomes. Although many predictive scoring systems exist, their complexity may limit utility in COVID-19. We assessed the prognostic performance of the National Early Warning Score (NEWS) and an age-based modification (NEWS+age) among hospitalized COVID-19 patients enrolled in a prospective, multicenter US Military Health System (MHS) observational cohort study. METHODS Hospitalized adults with confirmed COVID-19 not requiring invasive mechanical ventilation at admission and with a baseline NEWS were included. We analyzed each scoring system's ability to predict key clinical outcomes, including progression to invasive ventilation or death, stratified by baseline severity (low [0-3], medium [4-6], and high [≥7]). RESULTS Among 184 included participants, those with low baseline NEWS had significantly shorter hospitalizations (P < .01) and lower maximum illness severity (P < .001). Most (80.2%) of low NEWS vs 15.8% of high NEWS participants required no or at most low-flow oxygen supplementation. Low NEWS (≤3) had a negative predictive value of 97.2% for progression to invasive ventilation or death; a high NEWS (≥7) had high specificity (93.1%) but low positive predictive value (42.1%) for such progression. NEWS+age performed similarly to NEWS at predicting invasive ventilation or death (NEWS+age: area under the receiver operating characteristics curve [AUROC], 0.69; 95% CI, 0.65-0.73; NEWS: AUROC, 0.70; 95% CI, 0.66-0.75). CONCLUSIONS NEWS and NEWS+age showed similar test characteristics in an MHS COVID-19 cohort. Notably, low baseline scores had an excellent negative predictive value. Given their easy applicability, these scoring systems may be useful in resource-limited settings to identify COVID-19 patients who are unlikely to progress to critical illness.
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Affiliation(s)
- Ryan C Maves
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Naval Medical Center San Diego, San Diego, California, USA
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephanie A Richard
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - David A Lindholm
- Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Nusrat Epsi
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Derek T Larson
- Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA
| | - Christian Conlon
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, USA
| | - Kyle Everson
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, USA
| | - Steffen Lis
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, USA
| | - Paul W Blair
- Austere Environments Consortium for Enhanced Sepsis Outcomes, Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sharon Chi
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Simon Pollett
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Timothy H Burgess
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Brian K Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Rhonda E Colombo
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, USA
| | - Christopher J Colombo
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, USA
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16
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Supervision, Interprofessional Collaboration, and Patient Safety in Intensive Care Units during the COVID-19 Pandemic. ATS Sch 2021; 2:397-414. [PMID: 34667989 PMCID: PMC8519340 DOI: 10.34197/ats-scholar.2020-0165oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background: To meet coronavirus disease (COVID-19) demands in the spring of 2020, many intensive care (IC) units (ICUs) required help of redeployed personnel working outside their regular scope of practice, causing an expansion and change of staffing ratios. Objective: How did this composite alternative ICU workforce experience supervision, interprofessional collaboration, and quality and safety of care under the unprecedented clinical circumstances at the height of the first pandemic wave as lived experiences uniquely captured during the first peak of the pandemic? Methods: An international, cross-sectional survey was conducted among physicians, nurses, and allied personnel deployed or redeployed to ICUs in Utrecht, New York, and Dublin from April to May of 2020. Data were analyzed separately for the three sites. Quantitative data were treated for descriptive statistics; qualitative data were analyzed thematically and combined for general interpretations. Results: On the basis of 234, 83, and 34 responses (response rates of 68%, 48%, and 41% in Utrecht, New York, and Dublin, respectively), we found that the amount of supervision and the quality and safety of care were perceived as being lower than usual but still acceptable. The working atmosphere was overwhelmingly felt to be collaborative and supportive. Where IC-certified nurse-to-patient ratios had decreased most (Utrecht), nurses voiced criticism about supervision and quality of care. Continuity within the work environment, team composition, and informal ("curbside") consultations were critical mediators of success. Conclusion: In the exceptional circumstances encountered during the COVID-19 pandemic, many ICUs were managed by a composite workforce of IC-certified and redeployed personnel. Although supervision is critical for safe care, supervisory roles were not clearly related to the amount of prior ICU experience. Vital for satisfaction with the quality of care was the span of control for those who assumed supervisory roles (i.e., the ratio of certified to noncertified personnel). Stable teams that matched less experienced personnel with more experienced personnel; a strong, interprofessional, collaborative atmosphere; a robust culture of informal consultation; and judicious, more flexible use of rules and regulations proved to be essential.
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17
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Leykum LK, Kulkarni SA, O’Leary KJ. Hospital-Level Variability in Outcomes of Patients With COVID-19. J Hosp Med 2021; 16:255. [PMID: 33822714 PMCID: PMC8025593 DOI: 10.12788/jhm.3617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Luci K Leykum
- Department of Medicine, Dell Medical School, the University of Texas at Austin, Austin, Texas
- Medicine Service, South Texas Veterans Heath Care System, San Antonio, Texas
- Corresponding author: Luci K Leykum, MD, MBA, MSc; ; Telephone: 210-563-4527; @LeykumLuci
| | - Shradha A Kulkarni
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Kevin J O’Leary
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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