National Trends in Anticoagulation Therapy for COVID-19 Hospitalized Adults in the United States: Analyses of the National COVID Cohort Collaborative

BACKGROUND

Anticoagulation (AC) utilization patterns and their predictors among hospitalized coronavirus disease 2019 (COVID-19) patients have not been well described.

METHODS

Using the National COVID Cohort Collaborative, we conducted a retrospective cohort study (2020-2022) to assess AC use patterns and identify factors associated with therapeutic AC employing modified Poisson regression.

RESULTS

Among 162 842 hospitalized COVID-19 patients, 64% received AC and 24% received therapeutic AC. Therapeutic AC use declined from 32% in 2020 to 12% in 2022, especially after December 2021. Therapeutic AC predictors included age (relative risk [RR], 1.02; 95% confidence interval [CI], 1.02-1.02 per year), male (RR, 1.29; 95% CI, 1.27-1.32), non-Hispanic black (RR, 1.16; 95% CI, 1.13-1.18), obesity (RR, 1.48; 95% CI, 1.43-1.52), increased length of stay (RR, 1.01; 95% CI, 1.01-1.01 per day), and invasive ventilation (RR, 1.64; 95% CI, 1.59-1.69). Vaccination (RR, 0.88; 95% CI, 84-.92) and higher Charlson Comorbidity Index (CCI) (RR, 0.98; 95% CI, .97-.98) were associated with lower therapeutic AC.

CONCLUSIONS

Overall, two-thirds of hospitalized COVID-19 patients received any AC and a quarter received therapeutic dosing. Therapeutic AC declined after introduction of the Omicron variant. Predictors of therapeutic AC included demographics, obesity, length of stay, invasive ventilation, CCI, and vaccination, suggesting AC decisions driven by clinical factors including COVID-19 severity, bleeding risks, and comorbidities.

Racial differences in setting of implantable cardioverter-defibrillator placement in older adults with heart failure and association with disparate post-implant outcomes

Background

Implantable cardioverter-defibrillator (ICD) placement in heart failure (HF) patients during or early after (≤90 days) unplanned cardiovascular hospitalizations has been associated with poor outcomes. Racial and ethnic differences in this "peri-hospitalization" ICD placement have not been well described.

Methods

Using a 20% random sample of Medicare beneficiaries, we identified older (≥66 years) patients with HF who underwent ICD placement for primary prevention from 2008 to 2018. We investigated racial and ethnic differences in frequency of peri-hospitalization ICD placement using modified Poisson regression. We utilized Kaplan-Meier analyses and Cox regression to investigate the association of peri-hospitalization ICD placement with differences in all-cause mortality and hospitalization (HF, cardiovascular and all-cause) within and between race and ethnicity groups for up to 5-year follow-up.

Results

Among the 61,710 beneficiaries receiving ICDs (35% female, 82% White, 10% Black, 6% Hispanic), 44% were implanted peri-hospitalization. Black [adjusted rate ratio (RR) 95% Confidence Interval (95% CI): 1.16 (1.12, 1.20)] and Hispanic [RR (95% CI): 1.10 (1.06, 1.14)] beneficiaries were more likely than White beneficiaries to have ICD placement peri-hospitalization. Peri-hospitalization ICD placement was associated with an at least 1.5× increased risk of death, 1.5× increased risk of re-hospitalization and 1.7× increased risk of HF hospitalization during 3-year follow-up in fully adjusted models. Although beneficiaries with peri-hospitalization placement had the highest mortality and readmission rates 1- and 3-year post-implant (log-rank p < 0.0001), the magnitude of the associated risk did not differ significantly by race and ethnicity (p = NS for interaction).

Conclusions

ICD implantation occurring during the peri-hospitalization period was associated with worse prognosis and occurred at higher rates among Black and Hispanic compared to White Medicare beneficiaries with HF during the period under study. The risk associated with peri-hospitalization ICD placement did not differ by race and ethnicity. Future paradigms aimed at enhancing real-world effectiveness of ICD therapy and addressing disparate outcomes should consider timing and setting of ICD placement in HFrEF patients who otherwise meet guideline eligibility.

Abstract MP10: Healthy Diet Perception vs Actual Diet Quality for Cardiovascular Health: Prevalence and Predictors of Perceiving a Poor Diet as Healthy Among Adults

Objective: A healthy diet is key to preventing and managing CVD. Despite clear AHA guidelines, eating healthy can be difficult due to misinformation. We investigated perceived vs. actual diet quality and what contributes to perceiving a poor diet ‘healthy’.

Methods: We identified adults aged > 19 in 2005-2018 National Health and Nutrition Examination Survey. Healthy perceived diet was defined as answering “excellent” or “very good” to “how healthy is the diet?”. We assessed actual diet quality by calculating AHA Healthy Diet Score based on a 24-hour dietary recall and scaled the raw score to 0-100%; ‘poor diet’ was defined as AHA score < 40%. We first estimated prevalence of poor actual diet and perceived healthy diet. Among those with poor diet (AHA score < 40%), we fit modified-Poisson regression models to identify factors associated with perceiving a poor diet as ‘healthy’ and reported risk ratios with 95% confidence limits.

Results: Among 31,621 adults (50% female, mean age 50, 43% non-Hispanic White, mean BMI 29), prevalence of ‘healthy’ perceived diet and actual ‘poor diet’ was 29% and 47%, respectively. Among adults with a ‘poor diet’ (n=14,951), 23% perceived their diet as ‘healthy’ and many sociodemographic and lifestyle factors and comorbidities were significantly associated with perceiving a poor diet as healthy in univariate analyses (Table). In multivariable analysis, increased age, male sex, White race (compared to Black and Hispanic race), MI history, smaller waist circumference, higher physical activity, and alcohol use were independently associated with perceiving their poor diet as ‘healthy’ (RR ranged from 0.77-1.48, Table).

Conclusion: Nearly half of US adults had a poor diet based on dietary targets from AHA 2020 Strategic Impact Goals for CV health, yet nearly a quarter of them perceived their diet as ‘healthy’. Targeting high risk adults with focused educational interventions to calibrate their perception of a healthy diet can be effective in modifying their eating behavior and promoting CV health.

Does Frailty influence Inhospital Management and Outcomes of COVID-19 in Older Adults in the US?

Older age has been consistently associated with adverse COVID-19 outcomes. Frailty, a syndrome characterized by declining function across multiple body systems is common in older adults and may increase vulnerability to adverse outcomes among COVID-19 patients. However, the impacts of frailty on COVID-19 management, severity, or outcomes have not been well characterized in a large, representative US population. Using the National COVID Cohort Collaborative, a multi-institutional US repository for COVID-19 research, we calculated the Hospital Frailty Risk Score (HFRS), a validated EHR-based frailty score, among COVID-19 inpatients age ≥ 65. We examined patient demographics and comorbidities, length of stay (LOS), systemic corticosteroid and remdesivir use, ICU admission, and inpatient mortality across subgroups by HFRS score. Among 58,964 inpatients from 53 institutions (51% male, 65% White, 18% Black, 9% Hispanic, mean age 75, mean Charlson comorbidity count 3.0, and median LOS 7 days), 38,692 (66%), 4,180 (7%), 3,531 (6%), 3,525 (6%) and 7,862 (13%) had HFRS scores of 0-1, 2, 3, 4, and &gt;=5 , respectively. Frailty was only moderately correlated with age and comorbidity (ρ=0.178 and 0.348, respectively, p&lt;0.001). Overall, 34% received systemic corticosteroid and 19% received remdesivir. We observed 4% ICU admissions and 16% inpatient death. Among non-ICU admissions, after adjusting for demographics and comorbidities, frailty (HFRS ≥ 2) was associated with 79% greater systemic corticosteroid use and 22% greater remdesivir use, whereas a higher HRFS score was marginally associated with higher rates of severe COVID disease, inpatient death, or ICU admission.

Outcomes of COVID-19 in Patients With Cancer: Report From the National COVID Cohort Collaborative (N3C)

PURPOSE

Variation in risk of adverse clinical outcomes in patients with cancer and COVID-19 has been reported from relatively small cohorts. The NCATS' National COVID Cohort Collaborative (N3C) is a centralized data resource representing the largest multicenter cohort of COVID-19 cases and controls nationwide. We aimed to construct and characterize the cancer cohort within N3C and identify risk factors for all-cause mortality from COVID-19.

METHODS

We used 4,382,085 patients from 50 US medical centers to construct a cohort of patients with cancer. We restricted analyses to adults ≥ 18 years old with a COVID-19-positive or COVID-19-negative diagnosis between January 1, 2020, and March 25, 2021. We followed N3C selection of an index encounter per patient for analyses. All analyses were performed in the N3C Data Enclave Palantir platform.

RESULTS

A total of 398,579 adult patients with cancer were identified from the N3C cohort; 63,413 (15.9%) were COVID-19-positive. Most common represented cancers were skin (13.8%), breast (13.7%), prostate (10.6%), hematologic (10.5%), and GI cancers (10%). COVID-19 positivity was significantly associated with increased risk of all-cause mortality (hazard ratio, 1.20; 95% CI, 1.15 to 1.24). Among COVID-19-positive patients, age ≥ 65 years, male gender, Southern or Western US residence, an adjusted Charlson Comorbidity Index score ≥ 4, hematologic malignancy, multitumor sites, and recent cytotoxic therapy were associated with increased risk of all-cause mortality. Patients who received recent immunotherapies or targeted therapies did not have higher risk of overall mortality.

CONCLUSION

Using N3C, we assembled the largest nationally representative cohort of patients with cancer and COVID-19 to date. We identified demographic and clinical factors associated with increased all-cause mortality in patients with cancer. Full characterization of the cohort will provide further insights into the effects of COVID-19 on cancer outcomes and the ability to continue specific cancer treatments.

Outcomes of COVID-19 in cancer patients: Report from the National COVID Cohort Collaborative (N3C)

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Background: The impact of COVID-19 has disproportionately affected every aspect of cancer care and research—from introducing new risks for patients to disrupting the delivery of treatment and continuity of research. Variation in risk of adverse clinical outcomes in COVID-19 patients by cancer type has been reported from relatively small cohorts. Gaps in understanding effects of COVID-19 on cancer patients can be addressed through the study of a well-constructed representative cohort. The NCATS’ National COVID Cohort Collaborative (N3C) is a centralized data resource representing the largest multi-center cohort of COVID-19 cases and controls nationwide. We aimed to construct and characterize the cohort of cancer patients within N3C and identify risk factors for all-cause mortality from COVID-19. Methods: From the harmonized N3C clinical dataset, we used 3,295,963 patients from 39 medical US centers to construct a cancer patient cohort. We restricted analyses to adults ≥18 yo with a COVID-19 positive PCR or antigen test or ICD-10-CM diagnostic code for COVID-19 between 1/1/2020 and 2/14/2021. We followed N3C definitions where each lab-confirmed positive patient has one single index encounter. A modified WHO Clinical Progression Scale was used to determine clinical severity. All analyses were performed in the N3C Data Enclave on the Palantir platform. Results: A total of 372,883 adult patients with cancer were identified from the N3C cohort; 54,642 (14.7%) were COVID-19 positive. Most common represented cancers were skin (11.5%), breast (10.2%), prostate (8%), and lung cancer (5.6%). Mean age of COVID-19 positive patients was 61.6 years (SD 16.7), 47.3% over 65yo, 53.7% females, 67.2% non-Hispanic White, 21.0% Black, and 7.7% Hispanic or Latino. A total of 14.6% were current or former smokers, 22.3% had a Charlson Comorbidity Index (CCI) score of 0, 4.6% score of 1 and 28.1% score of 2. Among hospitalized COVID-19 positive patients, average length of stay in the hospital was 6 days (SD 23.1 days), 7.0% patients had died while in their initial COVID-19 hospitalization, 4.5% required invasive ventilation, and 0.1% extracorporeal membrane oxygenation. Survival probability was 86.4% at 10 days and 63.6% at 30 days. Older age over 65yo (Hazard ratio (HR) = 6.1, 95%CI: 4.3, 8.7), male gender (HR = 1.2, 95%CI: 1.1, 1.2), a CCI score of 2 or more (HR = 1.15, 95%CI: 1.1, 1.2), and acute kidney injury during hospitalization (HR = 1.3, 95%CI: 1.2, 1.4) were associated with increased risk of all-cause mortality. Conclusions: Using the N3C cohort we assembled the largest nationally representative cohort on patients with cancer and COVID-19 to date. We identified demographic and clinical factors associated with increased all-cause mortality in cancer patients. Full characterization of the cohort will provide further insights on the effects of COVID-19 on cancer outcomes and the ability to continue specific cancer treatments.