Association Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020

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Abstract

The effect of surges in COVID-19 caseload on COVID-19 survival rates is unclear, especially independent of temporal changes in survival. This retrospective cohort study used data from a large U.S. hospital database to study the association between caseload surges and risk-adjusted mortality in patients with COVID-19.

Abstract

Visual Abstract.

Association Between Caseload Surge and COVID-19 Survival in U.S. Hospitals.

Abstract

Background:

Several U.S. hospitals had surges in COVID-19 caseload, but their effect on COVID-19 survival rates remains unclear, especially independent of temporal changes in survival.

Objective:

To determine the association between hospitals' severity-weighted COVID-19 caseload and COVID-19 mortality risk and identify effect modifiers of this relationship.

Design:

Retrospective cohort study. (ClinicalTrials.gov: NCT04688372)

Setting:

558 U.S. hospitals in the Premier Healthcare Database.

Participants:

Adult COVID-19–coded inpatients admitted from March to August 2020 with discharge dispositions by October 2020.

Measurements:

Each hospital-month was stratified by percentile rank on a surge index (a severity-weighted measure of COVID-19 caseload relative to pre–COVID-19 bed capacity). The effect of surge index on risk-adjusted odds ratio (aOR) of in-hospital mortality or discharge to hospice was calculated using hierarchical modeling; interaction by surge attributes was assessed.

Results:

Of 144 116 inpatients with COVID-19 at 558 U.S. hospitals, 78 144 (54.2%) were admitted to hospitals in the top surge index decile. Overall, 25 344 (17.6%) died; crude COVID-19 mortality decreased over time across all surge index strata. However, compared with nonsurging (<50th surge index percentile) hospital-months, aORs in the 50th to 75th, 75th to 90th, 90th to 95th, 95th to 99th, and greater than 99th percentiles were 1.11 (95% CI, 1.01 to 1.23), 1.24 (CI, 1.12 to 1.38), 1.42 (CI, 1.27 to 1.60), 1.59 (CI, 1.41 to 1.80), and 2.00 (CI, 1.69 to 2.38), respectively. The surge index was associated with mortality across ward, intensive care unit, and intubated patients. The surge–mortality relationship was stronger in June to August than in March to May (slope difference, 0.10 [CI, 0.033 to 0.16]) despite greater corticosteroid use and more judicious intubation during later and higher-surging months. Nearly 1 in 4 COVID-19 deaths (5868 [CI, 3584 to 8171]; 23.2%) was potentially attributable to hospitals strained by surging caseload.

Limitation:

Residual confounding.

Conclusion:

Despite improvements in COVID-19 survival between March and August 2020, surges in hospital COVID-19 caseload remained detrimental to survival and potentially eroded benefits gained from emerging treatments. Bolstering preventive measures and supporting surging hospitals will save many lives.

Primary Funding Source:

Intramural Research Program of the National Institutes of Health Clinical Center, the National Institute of Allergy and Infectious Diseases, and the National Cancer Institute.

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Most cited references 43

Record: found
Abstract: found
Article: not found

Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report

Mark Peters (2020)

Abstract Background Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death. Methods In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the preliminary results of this comparison. Results A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55). Conclusions In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. (Funded by the Medical Research Council and National Institute for Health Research and others; RECOVERY ClinicalTrials.gov number, NCT04381936; ISRCTN number, 50189673.)

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Article: found

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

Safiya Richardson, Jamie Hirsch, Mangala Narasimhan … (2020)

There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19).

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Remdesivir for the Treatment of Covid-19 — Final Report

John H. Beigel, Kay Tomashek, Lori Dodd … (2022)

Abstract Background Although several therapeutic agents have been evaluated for the treatment of coronavirus disease 2019 (Covid-19), none have yet been shown to be efficacious. Methods We conducted a double-blind, randomized, placebo-controlled trial of intravenous remdesivir in adults hospitalized with Covid-19 with evidence of lower respiratory tract involvement. Patients were randomly assigned to receive either remdesivir (200 mg loading dose on day 1, followed by 100 mg daily for up to 9 additional days) or placebo for up to 10 days. The primary outcome was the time to recovery, defined by either discharge from the hospital or hospitalization for infection-control purposes only. Results A total of 1063 patients underwent randomization. The data and safety monitoring board recommended early unblinding of the results on the basis of findings from an analysis that showed shortened time to recovery in the remdesivir group. Preliminary results from the 1059 patients (538 assigned to remdesivir and 521 to placebo) with data available after randomization indicated that those who received remdesivir had a median recovery time of 11 days (95% confidence interval [CI], 9 to 12), as compared with 15 days (95% CI, 13 to 19) in those who received placebo (rate ratio for recovery, 1.32; 95% CI, 1.12 to 1.55; P<0.001). The Kaplan-Meier estimates of mortality by 14 days were 7.1% with remdesivir and 11.9% with placebo (hazard ratio for death, 0.70; 95% CI, 0.47 to 1.04). Serious adverse events were reported for 114 of the 541 patients in the remdesivir group who underwent randomization (21.1%) and 141 of the 522 patients in the placebo group who underwent randomization (27.0%). Conclusions Remdesivir was superior to placebo in shortening the time to recovery in adults hospitalized with Covid-19 and evidence of lower respiratory tract infection. (Funded by the National Institute of Allergy and Infectious Diseases and others; ACTT-1 ClinicalTrials.gov number, NCT04280705.)

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Author and article information

Journal

Journal ID (nlm-ta): Ann Intern Med

Journal ID (iso-abbrev): Ann Intern Med

Journal ID (publisher-id): aim

Title: Annals of Internal Medicine

Publisher: American College of Physicians

ISSN (Print): 0003-4819

ISSN (Electronic): 1539-3704

Publication date (Electronic): 6 July 2021

Electronic Location Identifier: M21-1213

Affiliations

[1 ]National Institutes of Health Clinical Center, Bethesda, Maryland (S.S.K., J.S., A.L., M.K., C.Y., S.M., J.K., R.L.D., C.Y.D., S.W.)

[2 ]National Institutes of Health Clinical Center, Bethesda, Maryland, and U.S. Public Health Service, Rockville, Maryland (J.R.S.)

[3 ]National Institutes of Health Clinical Center, Bethesda, Maryland, and Emory University School of Medicine, Atlanta, Georgia (L.M.B.)

[4 ]Emory University School of Medicine, Atlanta, Georgia (A.B.)

[5 ]National Institute of Allergy and Infectious Diseases, Bethesda, Maryland (J.P.D., E.R.)

[6 ]Children's Minnesota Research Institute, Minneapolis, Minnesota (A.B.S.)

[7 ]Frederick National Laboratory for Cancer Research, Frederick, Maryland (J.H.P.)

[8 ]Brigham and Women's Hospital, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (C.R., M.K.)

[9 ]National Institutes of Health Clinical Center, Bethesda, Maryland, and Mayo Clinic Arizona, Phoenix, Arizona (J.A.)

[10 ]U.S. Public Health Service, Rockville, Maryland, and Centers for Disease Control and Prevention, Atlanta, Georgia (T.K.B.)

[11 ]Centers for Disease Control and Prevention, Atlanta, Georgia (A.V.G., S.D.D.)

[12 ]Centers for Disease Control and Prevention, Atlanta, Georgia, and General Dynamics Information Technology, Falls Church, Virginia (W.B.)

Author notes

Note: Dr. Kadri had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Disclaimer: The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the U.S. Department of Health and Human Services, the National Institutes of Health, the Centers for Disease Control and Prevention, or the U.S. government, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.

Acknowledgment: The authors thank Timothy G. Buchman, MD, PhD (Biomedical Advanced Research and Development Authority), John Orav, PhD (Harvard T.H. Chan School of Public Health), Henry Masur, MD (National Institutes of Health Clinical Center), Jessica Young, PhD (Harvard Pilgrim Population Medicine Institute), and James Baggs, PhD, and Kelly Hatfield, MSPH (both from the CDC COVID-19 Response Team), for their insightful feedback on the topic that informed the design of the study. The authors also thank Mrs. Kelly Byrne for assisting with formatting of the manuscript. None of these people received financial compensation for their contributions.

Financial Support: This work was funded in part by the Intramural Research Program of the National Institutes of Health Clinical Center, the National Institute of Allergy and Infectious Diseases, and the National Cancer Institute (contract no. HHSN261200800001E).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-1213.

Reproducible Research Statement: Study protocol: Available on ClinicalTrials.gov (NCT04688372). Statistical code: Available at https://github.com/sarahwarner/COVID-19-Surge-Impact-on-Mortality. Data set: Not available.

Corresponding Author: Sameer S. Kadri, MD, MS, Clinical Epidemiology Section, Critical Care Medicine Department, NIH Clinical Center, 10 Center Drive, Building 10, Room 2C-145, Bethesda, MD 20892; e-mail, Sameer.kadri@ 123456nih.gov .

Current Author Addresses: Drs. Kadri, Sun, Lawandi, Strich, Keller, Yek, Malik, Danner, and Demirkale and Ms. Warner: NIH Clinical Center, 10 Center Drive, Building 10, Room 2C-145, Bethesda, MD 20892.

Drs. Busch and Babiker: Emory University Hospital Midtown Campus, 550 Peachtree Street Northeast, Atlanta, GA 30308.

Dr. Krack: NIH Clinical Center, 10 Center Drive, Building 10, 1C240J, Bethesda, MD 20892.

Dr. Dekker: National Institute of Allergy and Infectious Diseases, National Institutes of Health, 9000 Rockville Pike, Building 29, Room 5NN08, Bethesda, MD 20892.

Dr. Spaulding: National Institute of Allergy and Infectious Diseases, National Institutes of Health, 40 Convent Drive, Building 40, Room 1100, Bethesda, MD 20892.

Dr. Ricotta: National Institute of Allergy and Infectious Diseases, National Institutes of Health, 5601 Fishers Lane, Building 5601FL, Room 7D18, Rockville, MD 20892.

Dr. Powers: National Institute of Allergy and Infectious Diseases, National Institutes of Health, 5601 Fishers Lane, Building 5601FL, Room 4D50, Rockville, MD 20892.

Drs. Rhee and Klompas: Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215.

Dr. Athale: Critical Care Department, Mayo Clinic Arizona, 5881 East Mayo Boulevard, Phoenix, AZ 85054.

Dr. Boehmer: CDC Covid Task Force, 2400 Century Center, Room 6209, MS V24-6, Atlanta, GA 30345.

Dr. Gundlapalli: CDC Covid Task Force, 2400 Century Center, Room 6206, MS V24-6, Atlanta, GA 30345.

Mr. Bentley: CDC Covid Task Force, Roybal Building 24, MS H24-8, Atlanta, GA 30333.

Dr. Datta: CDC Covid Task Force, Roybal Building 24, Room 2107, MS H24-2, Atlanta, GA 30333.

Author Contributions: Conception and design: S.S. Kadri, A. Lawandi, C. Rhee, J. Athale, A.V. Gundlapalli, R.L. Danner, S. Warner.

Analysis and interpretation of the data: S.S. Kadri, J. Sun, A. Lawandi, J.R. Strich, M. Keller, S. Malik, A.B. Spaulding, E. Ricotta, J.H. Powers, J. Athale, A.V. Gundlapalli, W. Bentley, S.D. Datta, C.Y. Demirkale, S. Warner.

Drafting of the article: S.S. Kadri, S. Warner.

Critical revision of the article for important intellectual content: S.S. Kadri, J. Sun, A. Lawandi, J.R. Strich, L.M. Busch, M. Keller, A. Babiker, C. Yek, J. Krack, J.P. Dekker, A.B. Spaulding, E. Ricotta, J.H. Powers, C. Rhee, M. Klompas, T.K. Boehmer, A.V. Gundlapalli, S.D. Datta, R.L. Danner, S. Warner.

Final approval of the article: S.S. Kadri, J. Sun, A. Lawandi, J.R. Strich, L.M. Busch, M. Keller, A. Babiker, C. Yek, S. Malik, J. Krack, J.P. Dekker, A.B. Spaulding, E. Ricotta, J.H. Powers, C. Rhee, M. Klompas, J. Athale, T.K. Boehmer, A.V. Gundlapalli, W. Bentley, S.D. Datta, R.L. Danner, C.Y. Demirkale, S. Warner.

Provision of study materials or patients: S.S. Kadri, S. Warner.

Statistical expertise: S.S. Kadri, J. Sun, A.B. Spaulding, E. Ricotta, J.H. Powers, W. Bentley, C.Y. Demirkale.

Obtaining of funding: S.S. Kadri.

Administrative, technical, or logistic support: S.S. Kadri, T.K. Boehmer, S. Warner.

Collection and assembly of data: S.S. Kadri, J. Athale, S. Warner.

Author information

Sameer S. Kadri https://orcid.org/0000-0002-4420-9004

Alexander Lawandi https://orcid.org/0000-0001-7948-3161

Lindsay M. Busch https://orcid.org/0000-0002-5332-5883

Ahmed Babiker https://orcid.org/0000-0003-0578-4871

Alicen B. Spaulding https://orcid.org/0000-0002-4687-3259

Emily Ricotta https://orcid.org/0000-0001-9928-8275

John H. Powers III https://orcid.org/0000-0002-5150-5119

Michael Klompas https://orcid.org/0000-0001-8641-4498

William Bentley https://orcid.org/0000-0001-5289-6759

Robert L. Danner https://orcid.org/0000-0001-5715-3823

Sarah Warner https://orcid.org/0000-0002-4998-9257

Article

Publisher ID: aim-olf-M211213

DOI: 10.7326/M21-1213

PMC ID: 8276718

PubMed ID: 34224257

SO-VID: c3272c25-2e6a-48b6-9222-e76329e86b00

License:

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.

Association Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020

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Abstract

Abstract

Abstract

Background:

Objective:

Design:

Setting:

Participants:

Measurements:

Results:

Limitation:

Conclusion:

Primary Funding Source:

Related collections

Novel Coronavirus Disease COVID-19

Most cited references 43

Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report

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

Remdesivir for the Treatment of Covid-19 — Final Report

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