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      Patient Trajectories Among Persons Hospitalized for COVID-19 : A Cohort Study

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          Abstract

          This retrospective analysis from 5 Maryland and Washington, DC area hospitals determines factors on hospital admission predictive of severe disease or death from COVID-19 and describes patient trajectories and outcomes categorized using the WHO COVID-19 disease severity scale.

          Abstract

          Visual Abstract. Trajectories Among Patients Hospitalized for COVID-19 This retrospective analysis from 5 Maryland and Washington, DC, area hospitals determines factors on hospital admission predictive of severe disease or death from COVID-19 and describes patient trajectories and outcomes categorized using the WHO COVID-19 disease severity scale.
          Visual Abstract.
          Trajectories Among Patients Hospitalized for COVID-19

          This retrospective analysis from 5 Maryland and Washington, DC, area hospitals determines factors on hospital admission predictive of severe disease or death from COVID-19 and describes patient trajectories and outcomes categorized using the WHO COVID-19 disease severity scale.

          Abstract

          Background:

          Risk factors for progression of coronavirus 2019 (COVID-19) to severe disease or death are underexplored in U.S. cohorts.

          Objective:

          To determine the factors on hospital admission that are predictive of severe disease or death from COVID-19.

          Design:

          Retrospective cohort analysis.

          Setting:

          Five hospitals in the Maryland and Washington, DC, area.

          Patients:

          832 consecutive COVID-19 admissions from 4 March to 24 April 2020, with follow-up through 27 June 2020.

          Measurements:

          Patient trajectories and outcomes, categorized by using the World Health Organization COVID-19 disease severity scale. Primary outcomes were death and a composite of severe disease or death.

          Results:

          Median patient age was 64 years (range, 1 to 108 years); 47% were women, 40% were Black, 16% were Latinx, and 21% were nursing home residents. Among all patients, 131 (16%) died and 694 (83%) were discharged (523 [63%] had mild to moderate disease and 171 [20%] had severe disease). Of deaths, 66 (50%) were nursing home residents. Of 787 patients admitted with mild to moderate disease, 302 (38%) progressed to severe disease or death: 181 (60%) by day 2 and 238 (79%) by day 4. Patients had markedly different probabilities of disease progression on the basis of age, nursing home residence, comorbid conditions, obesity, respiratory symptoms, respiratory rate, fever, absolute lymphocyte count, hypoalbuminemia, troponin level, and C-reactive protein level and the interactions among these factors. Using only factors present on admission, a model to predict in-hospital disease progression had an area under the curve of 0.85, 0.79, and 0.79, at day 2, 4, and 7, respectively.

          Limitation:

          The study was done in a single health care system.

          Conclusion:

          A combination of demographic and clinical variables is strongly associated with severe COVID-19 disease or death and their early onset. The COVID-19 Inpatient Risk Calculator (CIRC), using factors present on admission, can inform clinical and resource allocation decisions.

          Primary Funding Source:

          Hopkins inHealth and COVID-19 Administrative Supplement for the HHS Region 3 Treatment Center from the Office of the Assistant Secretary for Preparedness and Response.

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          Author and article information

          Journal
          Ann Intern Med
          aim
          Annals of Internal Medicine
          American College of Physicians
          0003-4819
          1539-3704
          22 September 2020
          : M20-3905
          Affiliations
          [1 ]Johns Hopkins University School of Medicine, Baltimore, Maryland (B.T.G., M.L.R., P.N., J.H.G., H.M., T.M.N., B.S.K., P.M.H., R.B., D.R.T., M.G.B., A.R., A.G.)
          [2 ]Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (J.F., J.M., J.P., G.S., M.W., K.B., S.L.Z.)
          [3 ]Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, Maryland (M.R., B.W.)
          [4 ]Information Technology, Johns Hopkins Medicine, Baltimore, Maryland (M.G., K.H.)
          [5 ]Howard Country General Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland (M.S.A.)
          [6 ]Suburban Hospital, Johns Hopkins Medicine, Bethesda, Maryland (E.D.D.)
          [7 ]Sibley Memorial Hospital, Johns Hopkins Medicine, Washington, D.C. (J.A.)
          [8 ]Technology Innovation Center, Johns Hopkins University School of Medicine, Baltimore, Maryland (A.B.S.)
          Author notes
          Acknowledgment: The authors thank the Johns Hopkins Health System and its surrounding communities for working together to provide outstanding patient care and to keep each other safe during these extraordinary times.
          Financial Support: The data utilized were part of the JH-CROWN: The COVID PMAP Registry, which is based on the contribution of many patients and clinicians and funded by Hopkins inHealth, the Johns Hopkins Precision Medicine Program. Drs. Garibaldi, Muschelli, Robinson, and Gupta and Mr. Schumock received funding from the COVID-19 Administrative Supplement for the HHS Region 3 Treatment Center from the Office of the Assistant Secretary for Preparedness and Response.
          Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Garibaldi (e-mail, bgariba1@ 123456jhmi.edu ), along with information on the COVID-19 Inpatient Risk Calculator (CIRC). Data set: Not available.
          Corresponding Author: Brian T. Garibaldi, MD, MEHP, Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, 1830 East Monument Street, Fifth Floor, Baltimore, MD 21205; e-mail, bgariba1@ 123456jhmi.edu .
          Current Author Addresses: Drs. Garibaldi and Kim: Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, 1830 East Monument Street, Fifth Floor, Baltimore, MD 21205.
          Drs. Fiksel, Muschelli, Perin, Wang, Bandeen-Roche, and Zeger and Mr. Schumock: Division of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205-2179.
          Dr. Robinson: Division of Infectious Diseases, Johns Hopkins University School of Medicine, 1830 East Monument Street, 4th Floor, Baltimore, MD 21205.
          Dr. Rouhizadeh: Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD 21202.
          Dr. Nagy and Mr. Shah: Johns Hopkins Medicine Technology Innovation Center, 855 North Wolfe Street, Rangos Building, Suite 600 B, Baltimore, MD 21205.
          Mr. Gray, Mr. Malapati, and Ms. Bowring: Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205.
          Ms. Ghobadi-Krueger and Mr. Harkness: Information Technology, Johns Hopkins Health System, 1000 Lancaster Street, 4th Floor, Baltimore, MD 21202.
          Dr. Niessen: Division of Hospital Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287.
          Dr. Hill: Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287.
          Dr. Shafeeq Ahmed: Howard Country General Hospital, 5755 Cedar Lane, Columbia, MD 21044.
          Dr. Dobkin: Suburban Hospital , 8600 Old Georgetown Road, Bethesda, MD 20814.
          Dr. Blanding: Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.
          Dr. Abele: Sibley Memorial Hospital, 5255 Loughboro Road NW, Washington, DC 20016.
          Ms. Woods: Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD 21202.
          Dr. Thiemann: Division of Cardiology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287.
          Dr. Rosen: Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205-1832.
          Dr. Gupta: Center for Clinical Global Health Education, Johns Hopkins School of Medicine, 600 North Wolfe Street, Phipps 521, Baltimore, MD 21287.
          Author Contributions: Conception and design: B.T. Garibaldi, P.G. Nagy, M.M. Ghobadi-Krueger, T. Niessen, D. Thiemann, K. Bandeen-Roche, A. Rosen, S. Zeger, A. Gupta.
          Analysis and interpretation of the data: B.T. Garibaldi, J. Fiksel, J. Muschelli, M.L. Robinson, J. Perin, G. Schumock, P.G. Nagy, J.H. Gray, H. Malapati, B. Woods, D. Thiemann, M. Wang, K. Bandeen-Roche, S. Zeger, A. Gupta.
          Drafting of the article: B.T. Garibaldi, J. Fiksel, M.L. Robinson, M. Rouhizadeh, P.G. Nagy, J.H. Gray, H. Malapati, P.M. Hill, A. Rosen, S. Zeger, A. Gupta.
          Critical revision for important intellectual content: B.T. Garibaldi, J. Fiksel, M.L. Robinson, G. Schumock, P.G. Nagy, J.H. Gray, H. Malapati, B. Kim, D. Thiemann, K. Bandeen-Roche, A. Rosen, S. Zeger, A. Gupta.
          Final approval of the article: B.T. Garibaldi, J. Fiksel, J. Muschelli, M.L. Robinson, M. Rouhizadeh, J. Perin, G. Schumock, P.G. Nagy, J.H. Gray, H. Malapati, M.M. Ghobadi-Krueger, T. Niessen, B. Kim, P.M. Hill, M. Shafeeq Ahmed, E.D. Dobkin, R. Blanding, J. Abele, B. Woods, K.B. Harkness, D. Thiemann, M.G. Bowring, A.B. Shah, M. Wang, K. Bandeen-Roche, A. Rosen, S. Zeger, A. Gupta.
          Provision of study materials or patients: J. Abele, E.D. Dobkin, B.T. Garibaldi, T. Niessen
          Statistical expertise: B.T. Garibaldi, J. Fiksel, J. Muschelli, M.L. Robinson, G. Schumock, J.H. Gray, M.M. Ghobadi-Krueger, D. Thiemann, K. Bandeen-Roche, S. Zeger.
          Obtaining of funding: A.B. Shah, S. Zeger.
          Administrative, technical, or logistic support: B.T. Garibaldi, M. Rouhizadeh, P.G. Nagy, J.H. Gray, M.M. Ghobadi-Krueger, M. Shafeeq Ahmed, E.D. Dobkin, R. Blanding, B. Woods, K.B. Harkness, D. Thiemann, M.G. Bowring, A.B. Shah, S. Zeger, A. Gupta.
          Collection and assembly of data: B.T. Garibaldi, J. Fiksel, M. Rouhizadeh, P.G. Nagy, J.H. Gray, H. Malapati, M.M. Ghobadi-Krueger, B. Kim, B. Woods, K.B. Harkness, D. Thiemann, M.G. Bowring, A.B. Shah, S. Zeger, A. Gupta.
          Previous Posting: This manuscript was posted as a preprint on medRxiv on 26 May 2020. doi:10.1101/2020.05.24.20111864
          Author information
          https://orcid.org/0000-0001-8632-5567
          https://orcid.org/0000-0001-7067-1334
          https://orcid.org/0000-0001-6469-1750
          https://orcid.org/0000-0003-0376-8560
          https://orcid.org/0000-0002-9006-6112
          https://orcid.org/0000-0002-5482-6620
          https://orcid.org/0000-0003-2361-9896
          https://orcid.org/0000-0001-5108-7749
          https://orcid.org/0000-0002-3388-5867
          https://orcid.org/0000-0002-6710-0239
          https://orcid.org/0000-0002-7299-7730
          https://orcid.org/0000-0002-8374-4763
          https://orcid.org/0000-0001-7036-2718
          Article
          aim-olf-M203905
          10.7326/M20-3905
          7530643
          32960645
          79285a83-9cdd-4f10-8e7d-c620e59ed3cf
          Copyright @ 2020

          This article is made available via the PMC Open Access Subset for unrestricted re-use for research, analyses, and text and data mining through PubMed Central. Acknowledgement of the original source shall include a notice similar to the following: "© 2020 American College of Physicians. Some rights reserved. This work permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited." These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

          History
          Categories
          Original Research
          coronavirus, Coronavirus Disease 2019 (COVID-19)
          poc-eligible, POC Eligible
          3122457, COVID-19
          2357, Health care providers
          11279, SARS coronavirus
          9715, Patients
          6354, Upper respiratory tract infections
          1541398, Pulmonary diseases
          3282, Infectious diseases
          8910, Epidemiology
          7245, Lungs

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