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Fewer Baseline ICU Beds Mean Higher Odds of COVID-19 Death
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Mark Mascolini
COVID-19 patients cared for in US hospitals with fewer than 50 intensive care unit (ICU) beds before the pandemic began had 3-fold higher odds of in-hospital death than those in hospitals with at least 100 baseline ICU beds, according to results of a 65-center analysis [1]. Risk-adjusted proportion of COVID-19 patients who died varied extremely across the hospitals, from 6.6% to 80.8%.
The United States accounts for the biggest number of COVID-19 deaths in the world. Yet as authors of this multicenter US study observe, gaps remain in the understanding of epidemiologic factors, treatment, and outcomes in US patients with severe COVID-19. To address these needs, a lengthy list of investigators mounted the Study of the Treatment and Outcomes in Critically Ill Patients With COVID-19 (STOP-COVID).
The analysis focused on adults with laboratory-confirmed COVID-19 admitted to an ICU in 1 of 65 participating hospitals between March 4 and April 4, 2020. Follow-up continued until hospital discharge, death, or June 4, 2020, whichever came first. The primary outcome was death within 28 days of ICU admission. The STOP-COVID team used multilevel logistic regression to identify factors linked to death and to explore between-hospital variations in treatment and outcomes.
The 2215 study participated averaged 60.5 years in age and 65% were men; 30% were black and 20% Hispanic. Upon ICU admission, 67% of participants received invasive mechanical ventilation and 48% received vasopressors. In the first 14 days of ICU care, 84% received mechanical ventilation. The most-used medications were hydroxychloroquine (79.5%), azithromycin (59.6%), and therapeutic anticoagulants (41.5%).
While 784 people (35.4%) died within 28 days of arriving in the ICU, 824 (37.2%) got released from the hospital within 28 days, and 607 (27.4%) remained in the hospital. The most frequent causes of death were respiratory failure (92.7%), septic shock (39.7%), and kidney failure (37.6%). (Patients could have more than one cause of death.)
From hospital to hospital, risk- and reliability-adjusted death rates within 28 days of ICU admission ranged vastly from 6.6% to 80.8%. When the researchers further adjusted this analysis for number of hospital beds before the COVID-19 pandemic, the adjusted death rate still varied widely between hospitals, from 11.9% to 63.3%.
The number of ICU beds a hospital had before possible expansion for COVID-19 had a decided effect on risk of death within 28 days. Patients cared for in hospitals with fewer than 50 ICU beds before the pandemic had more than 3-fold higher odds of death within 28 days of ICU admission (adjusted odds ratio [OR] 3.28, 95% confidence interval [CI] 2.16 to 4.99). This analysis singled out 11 other independent predictors of 28-day mortality:
- 80+ vs under 40 years old: OR 11.15, 95% CI 6.19 to 20.06
- 70-79 vs under 40: OR 5.36, 95% CI 3.20 to 9.00
- 60-69 vs under 40: OR 3.18, 95% CI 1.95 to 5.18
- 50-59 vs under 40: OR 1.71, 95% CI 1.05 to 2.80
- Male sex: OR 1.50, 95% CI 1.19 to 1.90
- Body mass index 40+ vs under 25 kg/m2: OR 1.51, 95% CI 1.01 to 2.25
- Coronary artery disease: OR 1.47, 95% CI 1.07 to 2.02
- Active cancer: OR 2.15, 95% CI 1.35 to 3.43
- Hypoxemia (PaO2:FIO2 below 100 vs 300+ mm Hg: OR 2.94, 95% CI 2.11 to 4.08
- Liver dysfunction (liver SOFA score 2 vs 0): OR 2.61, 95% CI 1.30 to 5.25
- Kidney dysfunction (renal SOFA score 4 vs 0): OR 2.43, 95% CI 1.46 to 4.05
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SOFA, Sequential Organ Failure Assessment.
Factors that did not affect mortality in this analysis were race (race other than white vs white), hypertension, diabetes, and lymphocyte count.
Previous research underscored the impact of older age, greater weight, and comorbidities on poor outcomes with COVID-19. This appears to be the first study to forge a clear link between a hospital’s readiness to manage severe acute disease-measured in ICU bed numbers-and risk of death with COVID-19. A related finding spotlights the impact hospital choice or availability can have on survival with severe COVID-19. Even after statistical adjustment for ICU bed number, the researchers reckoned a yawing 51-point span in adjusted death rate across the 65 US centers involved in this study.
The authors observe that hospitals in this analysis varied widely in proportion of COVID-19 ICU patients who died and proportions who received medications and supportive therapy for COVID-19. At least some of this variation, they suggest, could involve “limited high-quality evidence on which to base clinical practice, variation in hospital resources to implement personnel-intensive interventions (eg, prone positioning), variation in the availability of certain medications (eg, remdesivir), or unmeasured variation in patient and practitioner characteristics across centers.”
Reference
1. Gupta S, Hayek SS, Wang W, et al. Factors associated with death in critically ill patients with coronavirus disease 2019 in the US. JAMA Intern Med. Published online July 15, 2020.
https://doi.org/10.1001/jamainternmed.2020.3596
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