The association of clinically relevant variables with chest radiograph lung disease burden quantified in real-time by radiologists upon initial presentation in individuals hospitalized with COVID-19

Objectives We aimed to correlate lung disease burden on presentation chest radiographs (CXR), quantified at the time of study interpretation, with clinical presentation in patients hospitalized with coronavirus disease 2019 (COVID-19). Material and methods This retrospective cross-sectional study included 5833 consecutive adult patients, aged 18 and older, hospitalized with a diagnosis of COVID-19 with a CXR quantified in real-time while hospitalized in 1 of 12 acute care hospitals across a multihospital integrated healthcare network between March 24, 2020, and May 22, 2020. Lung disease burden was quantified in real-time by 118 radiologists on 5833 CXR at the time of exam interpretation with each lung annotated by the degree of lung opacity as clear (0%), mild (1–33%), moderate (34–66%), or severe (67–100%). CXR findings were classified as (1) clear versus disease, (2) unilateral versus bilateral, (3) symmetric versus asymmetric, or (4) not severe versus severe. Lung disease burden was characterized on initial presentation by patient demographics, co-morbidities, vital signs, and lab results with chi-square used for univariate analysis and logistic regression for multivariable analysis. Results Patients with severe lung disease were more likely to have oxygen impairment, an elevated respiratory rate, low albumin, high lactate dehydrogenase, and high ferritin compared to non-severe lung disease. A lack of opacities in COVID-19 was associated with a low estimated glomerular filtration rate, hypernatremia, and hypoglycemia. Conclusions COVID-19 lung disease burden quantified in real-time on presentation CXR was characterized by demographics, comorbidities, emergency severity index, Charlson Comorbidity Index, vital signs, and lab results on 5833 patients. This novel approach to real-time quantified chest radiograph lung disease burden by radiologists needs further research to understand how this information can be incorporated to improve clinical care for pulmonary-related diseases.. An absence of opacities in COVID-19 may be associated with poor oral intake and a prerenal state as evidenced by the association of clear CXRs with a low eGFR, hypernatremia, and hypoglycemia.

Development and validation of self-monitoring auto-updating prognostic models of survival for hospitalized COVID-19 patients.

Clinical prognostic models can assist patient care decisions. However, their performance can drift over time and location, necessitating model monitoring and updating. Despite rapid and significant changes during the pandemic, prognostic models for COVID-19 patients do not currently account for these drifts. We develop a framework for continuously monitoring and updating prognostic models and apply it to predict 28-day survival in COVID-19 patients. We use demographic, laboratory, and clinical data from electronic health records of 34912 hospitalized COVID-19 patients from March 2020 until May 2022 and compare three modeling methods. Model calibration performance drift is immediately detected with minor fluctuations in discrimination. The overall calibration on the prospective validation cohort is significantly improved when comparing the dynamically updated models against their static counterparts. Our findings suggest that, using this framework, models remain accurate and well-calibrated across various waves, variants, race and sex and yield positive net-benefits.

The psychosocial health, experiences and needs of older adults and care partners during the first surge of the COVID-19 pandemic: a mixed-methods study.

BACKGROUND: Minimal research has leveraged qualitative data methods to gain a better understanding of the experiences and needs of older adults (OAs) and care partners of OAs with and without Alzheimer's Disease (AD) and AD-related dementias (AD/ADRD) during the first surge of the COVID-19 pandemic. In this study, we: 1) quantitatively evaluated the psychosocial health of community-dwelling OAs; 2) quantitatively evaluated the perceived stress of care partners for OAs; 3) qualitatively characterized the experiences and needs of community-dwelling OAs and their care partners; and 4) explored differences in the experiences of care partners of OAs with and without AD/ADRD during the first surge of the COVID-19 pandemic in the New York metropolitan area. METHODS: In this mixed-methods study, telephone interviews were conducted with 26 OAs and 29 care partners (16 of whom cared for OAs with AD/ADRD) from April to July 2020. Quantitative data included: demographics; clinical characteristics (Katz Index of independence in activities of daily living (Katz ADL) and the Lawton-Brody instrumental activities of daily living scale (Lawton-Brody)); and psychosocial health: stress was assessed via the Perceived Stress Scale (PSS), social isolation via the Lubben Social Network Scale (LSNS), loneliness via the DeJong Loneliness Scale (DeJong), and depression and anxiety via the Patient Health Questionnaire-Anxiety and Depression (PHQ). Qualitative questions focused on uncovering the experiences and needs of OAs and their care partners. RESULTS: OAs (N = 26) were mostly female (57.7%), and White (76.9%), average age of 81.42 years. While OAs were independent (M = 5.60, Katz ADL) and highly functional (M = 6.92, Lawton-Brody), and expressed low levels of loneliness, stress, depression and anxiety (M = 1.95 on DeJong; M = 12.67 on PSS; M = 1.05 on PHQ depression; and M = 1.09 on PHQ anxiety), open-ended questions elicited themes of fear and worry. Care partners (N = 29) were mostly female (75.9%), White (72.4%), and married (72.4%), and reported moderate stress (M = 16.52 on the PSS), as well as a psychological impact of the pandemic. CONCLUSIONS: Early in the pandemic, OAs reported minimal stress and loneliness; this may have been related to their reports of frequent interaction with family, even if only virtually. By contrast, care partners were moderately stressed and worried, potentially more than usual due to the additional challenges they face when trying to meet their loved ones' needs during a pandemic.

Early DNR in Older Adults Hospitalized with SARS-CoV-2 Infection During Initial Pandemic Surge.

The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8, P < .001), women (51.2% vs 43.6%, P = .012), with higher comorbidity index (3.88 vs 3.36, P < .001), facility-based (49.1% vs 19.1%, P < .001), with dementia (13.3% vs 4.6%, P < .001), and severely ill on presentation (57.9% vs 32.3%, P < .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10-4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40-.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21-.67), and shorter length of stay (LOS, 4.8 vs 10.3 days, P < .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85-1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40-.75), IMV (OR: 0.53, 95% CI: 0.29-.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30-.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.

Trajectories of hypoxemia and pulmonary mechanics of COVID-19 ARDS in the NorthCARDS dataset.

BACKGROUND: Understanding heterogeneity seen in patients with COVIDARDS and comparing to non-COVIDARDS may inform tailored treatments. METHODS: A multidisciplinary team of frontline clinicians and data scientists worked to create the Northwell COVIDARDS dataset (NorthCARDS) leveraging over 11,542 COVID-19 hospital admissions. The data was then summarized to examine descriptive differences based on clinically meaningful categories of lung compliance, and to examine trends in oxygenation. FINDINGS: Of the 1536 COVIDARDS patients in the NorthCARDS dataset, there were 531 (34.6%) who had very low lung compliance (< 20 ml/cmH2O), 970 (63.2%) with low-normal compliance (20-50 ml/cmH2O), and 35 (2.2%) with high lung compliance (> 50 ml/cmH2O). The very low compliance group had double the median time to intubation compared to the low-normal group (107.3 h (IQR 25.8, 239.2) vs. 39.5 h (IQR 5.4, 91.6)). Overall, 68.8% (n = 1057) of the patients died during hospitalization. In comparison to non-COVIDARDS reports, there were less patients in the high compliance category (2.2% vs. 12%, compliance ≥ 50 mL/cmH20), and more patients with P/F ≤ 150 (59.8% vs. 45.6%). There is a statistically significant correlation between compliance and P/F ratio. The Oxygenation Index is the highest in the very low compliance group (12.51, SD(6.15)), and lowest in high compliance group (8.78, SD(4.93)). CONCLUSIONS: The respiratory system compliance distribution of COVIDARDS is similar to non-COVIDARDS. In some patients, there may be a relation between time to intubation and duration of high levels of supplemental oxygen treatment on trajectory of lung compliance.

Geriatrics-focused indicators predict mortality more than age in older adults hospitalized with COVID-19.

BACKGROUND: Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to utilize administrative data to build an explanatory model accounting for geriatrics-focused indicators to predict mortality in hospitalized older adults with COVID-19. METHODS: Retrospective cohort study of adults age 65 and older (N = 4783) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Stepwise logistic regression with Akaike Information Criterion minimization was used. RESULTS: The average age was 77.4 (SD = 8.4), 55.9% were male, 20.3% were African American, and 15.0% were Hispanic. In multivariable analysis, male sex (adjusted odds ration (adjOR) = 1.06, 95% CI:1.03-1.09); Asian race (adjOR = 1.08, CI:1.03-1.13); history of chronic kidney disease (adjOR = 1.05, CI:1.01-1.09) and interstitial lung disease (adjOR = 1.35, CI:1.28-1.42); low or normal body mass index (adjOR:1.03, CI:1.00-1.07); higher comorbidity index (adjOR = 1.01, CI:1.01-1.02); admission from a facility (adjOR = 1.14, CI:1.09-1.20); and mechanical ventilation (adjOR = 1.52, CI:1.43-1.62) were associated with mortality. While age was not an independent predictor of mortality, increasing age (centered at 65) interacted with hypertension (adjOR = 1.02, CI:0.98-1.07, reducing by a factor of 0.96 every 10 years); early Do-Not-Resuscitate (DNR, life-sustaining treatment preferences) (adjOR = 1.38, CI:1.22-1.57, reducing by a factor of 0.92 every 10 years); and severe illness on admission (at 65, adjOR = 1.47, CI:1.40-1.54, reducing by a factor of 0.96 every 10 years). CONCLUSION: Our findings highlight that residence prior to admission, early DNR, and acute illness severity are important predictors of mortality in hospitalized older adults with COVID-19. Readily available administrative geriatrics-focused indicators that go beyond age can be utilized when considering prognosis.

Patient Factors and Hospital Outcomes Associated With Atypical Presentation in Hospitalized Older Adults With COVID-19 During the First Surge of the Pandemic.

BACKGROUND: Literature indicates an atypical presentation of COVID-19 among older adults (OAs). Our purpose is to identify the frequency of atypical presentation and compare demographic and clinical factors, and short-term outcomes, between typical versus atypical presentations in OAs hospitalized with COVID-19 during the first surge of the pandemic. METHODS: Data from the inpatient electronic health record were extracted for patients aged 65 and older, admitted to our health systems' hospitals with COVID-19 between March 1 and April 20, 2020. Presentation as reported by the OA or his/her representative is documented by the admitting professional and includes both symptoms and signs. Natural language processing was used to code the presence/absence of each symptom or sign. Typical presentation was defined as words indicating fever, cough, or shortness of breath; atypical presentation was defined as words indicating functional decline or altered mental status. RESULTS: Of 4 961 unique OAs, atypical presentation characterized by functional decline or altered mental status was present in 24.9% and 11.3%, respectively. Atypical presentation was associated with older age, female gender, Black race, non-Hispanic ethnicity, higher comorbidity index, and the presence of dementia and diabetes mellitus. Those who presented typically were 1.39 times more likely than those who presented atypically to receive intensive care unit-level care. Hospital outcomes of mortality, length of stay, and 30-day readmission were similar between OAs with typical versus atypical presentations. CONCLUSION: Although atypical presentation in OAs is not associated with the same need for acute intervention as respiratory distress, it must not be dismissed.

Age Does Not Predict Mortality in Hospitalized COVID-19+ Older Adults: Rethinking Resource Allocation Based on Age

Older adults are disproportionately affected by the coronavirus (COVID-19) pandemic. While age has been used to guide resource allocation based on studies implicating age as the main risk factor for COVID-19-related mortality, most did not account for critical factors such as baseline functional and cognitive status, or life-sustaining treatment preferences. The objective of this study was to determine whether age is independently associated with mortality in older adults hospitalized with COVID-19. We conducted a retrospective cohort study of adults age 65+ with confirmed COVID-19 hospitalized in the greater NY metropolitan area between 3/1/20-4/20/20. Primary outcome was in-hospital mortality, with age as the primary predictor. Multivariate logistic regression was used to evaluate association between age and in-hospital mortality after controlling for demographics, severity of acute illness, comorbidities, and baseline function, cognition, and life-sustaining treatment preferences. 4,969 patients were included, average age 77.3, 56.0% male, 46.8% White, 20.8% African American, 15.1% Hispanic. Common comorbidities included hypertension (61.1%), and diabetes (36.8%);average number of comorbidities was 3.4 (SD 2.8) and 13.0% had dementia. 20.8% arrived from a facility and 5.7% had early do-not-resuscitate orders. On arrival, the Modified Early Warning System score was 4.2 (SD 1.7) and 79.6% required oxygen therapy. 35.3% of patients expired. In multivariate analysis, age was not independently associated with mortality (p = .173). Functional status, multi-morbidity, life-sustaining treatment preferences, and illness severity, not age, were associated with mortality among older adults hospitalized with COVID-19, suggesting age should not be used as the main indicator to guide resource allocation.