Nationwide Analysis of the Outcomes and Mortality of Hospitalized COVID-19 Patients

Introduction: The Coronavirus disease 2019 (COVID-19) pandemic has affected people worldwide with the United States (US) with the largest number of reported cases currently. Previous studies in hospitalized COVID-19 patients have been limited by sample size. Methods: The National Inpatient Sample database which is the largest inpatient database in the US was queried in the year 2020 for the diagnosis of COVID-19 based on ICD-10-CM U07.1 and associated outcomes. Multivariate logistic regression analysis was used to identify predictors of mortality. STATA 16.0 was used for statistical analysis. Results: A weighted total of 1,678,995 hospitalizations for COVID-19 were identified. Median age of admitted patients with COVID-19 was 65 year (51-77) with 47.9% female and 49.2% White. Majority of the patients admitted were >65 years of age (49.3%). Hypertension and diabetes were the most common comorbidities (64.2% and 39.5%, respectively). Overall inpatient mortality was 13.2% and increasing to 55.9% in patients requiring mechanical ventilation. Trend of inpatient mortality was significantly decreasing over the year. Predictors of inpatient mortality included age, male sex, diabetes, chronic kidney disease, heart failure, arrythmia, obesity, and coagulopathy. Despite a lower proportion of patients admitted to hospital with COVID-19, Black, Hispanic, and Native Americans were at an increased adjusted odds of inpatient mortality. Disparity was also noted in income, with low median household income associated with higher risk of mortality. Conclusion: In the largest US cohort with >1.6 million hospitalized COVID-19 patients in 2020, overall inpatient mortality was 13.6% with significantly higher mortality in ventilated patients. Significant socioeconomic and racial disparities were present with minorities at higher odds of mortality.     

Impact of COVID-19 on Patients Hospitalized With Deep Vein Thrombosis and/or Pulmonary Embolism: A Nationwide Analysis

The Coronavirus disease 2019 (COVID-19) infection predisposes patients to develop deep vein thrombosis (DVT) and pulmonary embolism (PE). In this study, we compared the in-hospital outcomes of patients with DVT and/or PE with concurrent COVID-19 infection vs those with concurrent flu infection. The National Inpatient Sample from 2019 to 2020 was analyzed to identify all adult admissions diagnosed with DVT and PE. These patients were then stratified based on whether they had concomitant COVID-19 or flu. We identified 62,895 hospitalizations with the diagnosis of DVT and/or PE with concomitant COVID-19, and 8155 hospitalizations with DVT and/or PE with concomitant flu infection. After 1:1 propensity score match, the incidence of cardiac arrest and inpatient mortality were higher in the COVID-19 group. The incidence of cardiogenic shock was higher in the flu group. Increased age, Hispanic race, diabetes, chronic kidney disease, arrhythmia, liver disease, coagulopathy, and rheumatologic diseases were the independent predictors of mortality in patients with DVT and/or PE with concomitant COVID-19.     

Impact of Race and Socioeconomic Status on Outcomes in Patients Hospitalized with COVID-19

BackgroundThe impact of race and socioeconomic status on clinical outcomes has not been quantified in patients hospitalized with coronavirus disease 2019 (COVID-19).ObjectiveTo evaluate the association between patient sociodemographics and neighborhood disadvantage with frequencies of death, invasive mechanical ventilation (IMV), and intensive care unit (ICU) admission in patients hospitalized with COVID-19.DesignRetrospective cohort study.SettingFour hospitals in an integrated health system serving southeast Michigan.ParticipantsAdult patients admitted to the hospital with a COVID-19 diagnosis confirmed by polymerase chain reaction.Main MeasuresPatient sociodemographics, comorbidities, and clinical outcomes were collected. Neighborhood socioeconomic variables were obtained at the census tract level from the 2018 American Community Survey. Relationships between neighborhood median income and clinical outcomes were evaluated using multivariate logistic regression models, controlling for patient age, sex, race, Charlson Comorbidity Index, obesity, smoking status, and living environment.Key ResultsBlack patients lived in significantly poorer neighborhoods than White patients (median income: $34,758 (24,531–56,095) vs. $63,317 (49,850–85,776), p < 0.001) and were more likely to have Medicaid insurance (19.4% vs. 11.2%, p < 0.001). Patients from neighborhoods with lower median income were significantly more likely to require IMV (lowest quartile: 25.4%, highest quartile: 16.0%, p < 0.001) and ICU admission (35.2%, 19.9%, p < 0.001). After adjusting for age, sex, race, and comorbidities, higher neighborhood income ($10,000 increase) remained a significant negative predictor for IMV (OR: 0.95 (95% CI 0.91, 0.99), p = 0.02) and ICU admission (OR: 0.92 (95% CI 0.89, 0.96), p < 0.001).ConclusionsNeighborhood disadvantage, which is closely associated with race, is a predictor of poor clinical outcomes in COVID-19. Measures of neighborhood disadvantage should be used to inform policies that aim to reduce COVID-19 disparities in the Black community.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06527-1.KEY WORDS: COVID-19, disparities, disadvantage, socioeconomic status, race     

Disease Course and Outcomes of COVID-19 Among Hospitalized Patients With Gastrointestinal Manifestations

Background & AimsOur understanding of outcomes and disease time course of COVID-19 in patients with gastrointestinal (GI) symptoms remains limited. In this study we characterize the disease course and severity of COVID-19 among hospitalized patients with gastrointestinal manifestations in a large, diverse cohort from the Unites States.MethodsThis retrospective study evaluated hospitalized individuals with COVID-19 between March 11 and April 28, 2020 at two affiliated hospitals in New York City. We evaluated the association between GI symptoms and death, and also explored disease duration, from symptom onset to death or discharge.ResultsOf 2804 patients hospitalized with COVID-19, the 1,084 (38.7%) patients with GI symptoms were younger (aOR for age ≥75, 0.59; 95% CI, 0.45-0.77) and had more co-morbidities (aOR for modified Charlson comorbidity score ≥2, 1.22; 95% CI, 1.01-1.48) compared to those without GI symptoms. Individuals with GI symptoms had better outcomes, with a lower likelihood of intubation (aHR, 0.66; 95% CI, 0.55-0.79) and death (aHR, 0.71; 95% CI, 0.59-0.87), after adjusting for clinical factors. These patients had a longer median disease course from symptom onset to discharge (13.8 vs 10.8 days, log-rank p = .048; among 769 survivors with available symptom onset time), which was driven by longer time from symptom onset to hospitalization (7.4 vs 5.4 days, log-rank P < .01).ConclusionHospitalized patients with GI manifestations of COVID-19 have a reduced risk of intubation and death, but may have a longer overall disease course driven by duration of symptoms prior to hospitalization.     

Six-Month Outcomes in Patients Hospitalized with Severe COVID-19

BackgroundPrevious work has demonstrated that patients experience functional decline at 1–3 months post-discharge after COVID-19 hospitalization.ObjectiveTo determine whether symptoms persist further or improve over time, we followed patients discharged after hospitalization for severe COVID-19 to characterize their overall health status and their physical and mental health at 6 months post-hospital discharge.DesignProspective observational cohort study.ParticipantsPatients ≥ 18 years hospitalized for COVID-19 at a single health system, who required at minimum 6 l of supplemental oxygen during admission, had intact baseline functional status, and were discharged alive.Main MeasuresOverall health status, physical health, mental health, and dyspnea were assessed with validated surveys: the PROMIS® Global Health-10 and PROMIS® Dyspnea Characteristics instruments.Key ResultsOf 152 patients who completed the 1 month post-discharge survey, 126 (83%) completed the 6-month survey. Median age of 6-month respondents was 62; 40% were female. Ninety-three (74%) patients reported that their health had not returned to baseline at 6 months, and endorsed a mean of 7.1 symptoms. Participants’ summary t-scores in both the physical health and mental health domains at 6 months (45.2, standard deviation [SD] 9.8; 47.4, SD 9.8, respectively) remained lower than their baseline (physical health 53.7, SD 9.4; mental health 54.2, SD 8.0; p<0.001). Overall, 79 (63%) patients reported shortness of breath within the prior week (median score 2 out of 10 (interquartile range [IQR] 0–5), vs 42 (33%) pre-COVID-19 infection (0, IQR 0–1)). A total of 11/124 (9%) patients without pre-COVID oxygen requirements still needed oxygen 6 months post-hospital discharge. One hundred and seven (85%) were still experiencing fatigue at 6 months post-discharge.ConclusionsEven 6 months after hospital discharge, the majority of patients report that their health has not returned to normal. Support and treatments to return these patients back to their pre-COVID baseline are urgently needed.Graphical abstract Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07032-9.KEY WORDS: COVID-19, long-COVID, post-discharge outcomes, patient-reported outcomes     

Nationwide Analysis of the Clinical Outcomes of Patients Admitted With COVID-19 Infection With Myocarditis and Racial Disparities in Mortality

Coronavirus-19 (COVID-19), while primarily a respiratory virus, affects multiple organ systems, including the cardiovascular system. The relationship between COVID-19 and Myocarditis has been well established, but there are limited large-scale studies evaluating outcome of COVID-19 related Myocarditis. Using National Inpatient Sample (NIS) database, we compared patients with Myocarditis with and without COVID-19 infection. The primary outcome was in-hospital mortality. Secondary outcomes were acute kidney injury requiring hemodialysis, vasopressor use, mechanical ventilation, cardiogenic shock, mechanical circulatory support, sudden cardiac arrest, and length of hospitalization. A total of 17,970 patients were included in study; Myocarditis without COVID (n = 11,515, 64%) and Myocarditis with COVID-19 (n = 6,455, 36%). Patients with COVID-19 and Myocarditis had higher in-hospital mortality compared to those with Myocarditis alone (30.7% vs 6.4%, odds ratio 4.8, 95% CI 3.7-6.3, P< 0.001). That cohort also had significantly higher rates of vasopressor use, mechanical ventilation, sudden cardiac arrest, and acute kidney injury requiring hemodialysis. Given the poor outcome seen in COVID-19 related Myocarditis cohort, further work is needed for development of directed therapies for COVID-19-related Myocarditis.     

Proteinuria and Clinical Outcomes in Hospitalized COVID-19 Patients: A Retrospective Single-Center Study

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Impact of Stent Types on In-Hospital Outcomes of Patients With Cancer Undergoing Percutaneous Coronary Intervention: A Nationwide Analysis

BackgroundCardiovascular disease and cancer frequently coexist, and patients with cancer are at increased risk of cardiovascular events, including myocardial infarction and stroke. However, the impact of stent types on in-hospital outcomes of patients with malignancy is largely unknown.MethodsPatients with concomitant diagnosis of cancer undergoing PCI between January 2005 and December 2014 were identified in the National Inpatient Sample. They were then categorized into those who have undergone coronary stenting with bare-metal stent (BMS) or drug-eluting stent (DES). Primary outcomes were in-hospital mortality and stent thrombosis. Adjusted and unadjusted analysis was employed on appropriate variables of interest.Results8755 patients were included in the BMS group and 11,611 patients in the DES group. Following propensity matching, 4313 patients were randomly selected in both groups using a 1:1 ratio. There was high use of BMS stent in cancer patient (BMS 43.0%, DES 57.0%) compared to general population (BMS 23.2%, DES 76.8%). When comparing BMS to DES group, there was no statistically significant difference in mortality (4.7% vs. 3.8%, p = 0.097), acute kidney injury (11.3% vs. 10.6%, p = 0.425), bleeding complications (3.50% vs. 3.45%, p = 0.914), and length of hospital stay (5.4% vs. 5.2%, p = 0.119). However, an increased incidence of stent thrombosis was observed in the DES group (4.26% vs. 3.01%, p = 0.002).ConclusionA higher incidence of BMS placement was noted in patients with cancer than in the general population. Paradoxically there was a high incidence of stent thrombosis in the DES group without increasing mortality.     

Tocilizumab in Hospitalized Patients with COVID-19: A Meta Analysis of Randomized Controlled Trials

Lung - To date, only dexamethasone has been shown to reduce mortality in coronavirus disease-19 (COVID-19) patients. Tocilizumab has been recently added to the treatment guidelines for hospitalized...     

Care for Incarcerated Patients Hospitalized with COVID-19

The COVID-19 pandemic has reshaped health care delivery for all patients but has distinctly affected the most marginalized people in society. Incarcerated patients are both more likely to be infected and more likely to die from COVID-19. There is a paucity of guidance for the care of incarcerated patients hospitalized with COVID-19. This article will discuss how patient privacy, adequate communication, and advance care planning are rights that incarcerated patients may not experience during this pandemic. We highlight the role of compassionate release and note how COVID-19 may affect this prospect. A number of pragmatic recommendations are made to attenuate the discrepancy in hospital care experienced by those admitted from prisons and jails. Physicians must be familiar with the relevant hospital policies, be prepared to adapt their practices in order to overcome barriers to care, such as continuous shackling, and advocate to change these policies when they conflict with patient care. Stigma, isolation, and concerns over staff safety are shared experiences for COVID-19 and incarcerated patients, but incarcerated patients have been experiencing this treatment long before the current pandemic. It is crucial that the internist demand the equitable care that we seek for all our patients.     

Clinical Outcomes of Patients Hospitalized with Coronavirus Disease 2019 (COVID-19) in Boston

BackgroundOutcomes of hospitalized patients with COVID-19 have been described in health systems overwhelmed with a surge of cases. However, studies examining outcomes of patients admitted to hospitals not in crisis are lacking.ObjectiveTo describe clinical characteristic and outcomes of all patients with COVID-19 who are admitted to hospitals not in crisis, and factors associated with mortality in this population.DesignA retrospective analysisParticipantsIn total, 470 consecutive patients with COVID-19 requiring hospitalization in one health system in Boston from January 1, 2020 to April 15, 2020.Main MeasuresWe collected clinical outcomes during hospitalization including intensive care unit (ICU) admission, receipt of mechanical ventilation, and vasopressors. We utilized multivariable logistic regression models to examine factors associated with mortality.Key ResultsA total of 470 patients (median age 66 [range 23–98], 54.0% male) were included. The most common comorbidities were diabetes (38.5%, 181/470) and obesity (41.3%, 194/470). On admission, 41.9% (197/470) of patients were febrile and 60.6% (285/470) required supplemental oxygen. During hospitalization, 37.9% (178/470) were admitted to the ICU, 33.6% (158/470) received mechanical ventilation, 29.4% (138/470) received vasopressors, 16.4% (77/470) reported limitations on their desire for life-sustaining therapies such as intubation and cardiopulmonary resuscitation, and 25.1% (118/470) died. Among those admitted to the ICU (N=178), the median number of days on the ventilator was 10 days (IQR 1–29), and 58.4% (104/178) were discharged alive. Older age (OR=1.04, P<0.001), male sex (OR=2.14, P=0.007), higher comorbidities (OR=1.20, P=0.001), higher lactate dehydrogenase on admission (2nd tertile: OR=4.07, P<0.001; 3rd tertile: OR=8.04, P<0.001), and the need for supplemental oxygen on admission (OR=2.17, P=0.014) were all associated with higher mortality.ConclusionsThe majority of hospitalized patients with COVID-19 and those who received mechanical ventilation survived. These data highlight the need to examine public health and system factors that contribute to improved outcomes for this population.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06622-x.