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Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US
Shruti Gupta1, Salim S Hayek2, Wei Wang3
1Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Insights
Critical illness from coronavirus disease 2019 (COVID-19) in the US has high mortality. Factors like older age, male sex, comorbidities, and hospital bed capacity influenced patient survival, highlighting areas for improved care.
Area of Science:
- Critical care medicine
- Infectious diseases
- Epidemiology
Background:
- The United States became an epicenter for coronavirus disease 2019 (COVID-19), yet comprehensive national data on critically ill patients were scarce.
- Understanding patient characteristics, treatments, and outcomes is crucial for managing the pandemic.
Purpose of the Study:
- To identify factors associated with mortality in critically ill COVID-19 patients.
- To examine variations in treatment and outcomes across different hospitals.
Main Methods:
- A multicenter cohort study included 2215 adults with confirmed COVID-19 admitted to intensive care units (ICUs) across 65 US hospitals.
- Data on patient demographics, comorbidities, organ dysfunction, and hospital characteristics were collected.
- Multilevel logistic regression analyzed factors linked to death and interhospital outcome disparities.
Main Results:
- Overall 28-day in-hospital mortality was 35.4%, with 39.5% mortality at study end.
- Independent risk factors for death included older age, male sex, higher BMI, coronary artery disease, active cancer, hypoxemia, liver, and kidney dysfunction.
- Hospitals with fewer ICU beds (<50) showed a higher risk of death (OR, 3.28).
Conclusions:
- Demographic, clinical, and hospital-level factors are associated with death in critically ill COVID-19 patients.
- Findings can guide the identification of effective treatments and supportive therapies to improve patient outcomes.
- Significant interhospital variation in outcomes suggests a need for standardized critical care protocols.
Importance:
The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19.
Objectives:
To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19.
Design, Setting, And Participants:
This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020.
Exposures:
Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds.
Main Outcomes And Measures:
The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes.
Results:
A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (≥80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (≥40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (Pao2:Fio2<100 vs ≥300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2-4 vs 0: OR, 2.61; 95% CI, 1.30-5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46-4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs ≥100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies.
Conclusions And Relevance:
This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.
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