Metabolic Syndrome Is Associated With Worse Outcomes in SARS-CoV-2 Positive Emergency Department Patients

Study Objective: Increased body mass index (BMI) and metabolic syndrome (MetS) have been associated with adverse outcomes in numerous diseases. However, the role of BMI and MetS in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection remains unclear. We sought to examine the associations of increased BMI and MetS on several clinical outcomes in all ED patients tested for SARS-CoV-2 and then in the subset of COVID positive patients only. Methods: The REgistry of potential COVID-19 in emERgency care (RECOVER) is an observational study of SARS-CoV-2 tested patients from 155 US EDs. Inclusion criteria were a nucleic acid test at index visit. Body mass was categorized per CDC designations ie, BMI 18.5 to <25 kg/m2, 25 to <30 kg/m2, 30 to <35 kg/m2, 35 to <40 kg/m2 and ≥40 kg/m2. The presence of metabolic syndrome was defined as having 3 or more defining characteristics per the electronic medical record at the time of index visit;these included an elevated BMI (≥30 kg/m2), hyperlipidemia, hypertension, and diabetes. We used multivariable logistic regression to test for associations of several variables (including BMI, MetS, age, sex, race, ethnicity, and smoking) on the following clinical outcomes, first comparing SARS-CoV-2 positive and SARS-CoV-2 negative patients (N=27, 051) and then in the COVID+ subset (N=14, 056): hospital admission, intensive care unit (ICU) care, intubation, 30-day mortality and 30-day new or recurrent venous thromboembolism (VTE). Results: We report that BMI ≥ 30 kg/m2 was associated with SARS-CoV-2 test positivity (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.08-1.20). Analysis of BMI ≥ 40 kg/m2 revealed a stronger association with test positivity (OR 1.24, 95% CI 1.14-1.35). By contrast, MetS was not associated with testing positive (OR 0.95, 95% CI 0.89-1.01) in the overall cohort. In COVID+ patients, BMI ≥ 40 kg/m2 was associated with ICU care (adjusted odds ratio [aOR] 1.97;95% CI 1.65-2.35), intubation (aOR 2.69;95% CI 2.22-3.26) and mortality (aOR 1.50;95% CI 1.22-1.84). MetS was associated with worsened clinical outcomes: hospital admission (aOR 2.11;95% CI 1.89-2.37), ICU care (aOR 1.58;95% CI 1.40-1.78), intubation (aOR 1.46;95% CI 1.28-1.66), mortality (aOR 1.29;95% CI 1.13-1.48) and VTE (aOR 1.51;95% CI 1.07-2.13). Conclusions: In this large nationwide sample of ED patients undergoing SARS-CoV-2 testing, we report that BMI ≥ 30 kg/m2, BMI ≥ 40 kg/m2 and not MetS was associated with SARS-CoV-2 test positivity. Multivariable analysis in COVID positive patients only revealed significant associations of BMI ≥ 40 kg/m2 with three outcomes (ICU care, intubation and mortality) and of MetS with five outcomes (hospital admission, ICU care, intubation, mortality and VTE).

Health Insurance and Duration of Symptoms Prior to Emergency Department Visit: An Analysis of 19,850 Patients With Suspected COVID-19

Study Objectives: The COVID-19 pandemic has emphasized disparities in health outcomes across social and economic strata. The mechanisms of this relationship are poorly understood, but the length of time patients exhibit symptoms prior to getting tested for COVID-19 increases the opportunity for community transmission. We hypothesized that there is a relationship between insurance coverage and the duration of COVID-19 symptoms prior to seeking care at the emergency department (ED). Methods: A national, multi-institution (n=45 sites) registry collected information on ED visits in which patients were tested for suspected COVID-19. Demographics and clinical characteristics were summarized for the total cohort. Insurance was categorized into private (private or commercial), public (Medicare, Medicaid, or dual-eligible), worker’s compensation or unknown, or no health insurance. Negative binomial regression was used to analyze both the unadjusted and adjusted relationship between insurance and the time from symptom onset to ED presentation. Adjustments included age, sex, race, ethnicity, medical history, smoking status, drug use, and number of COVID symptoms. Results: Baseline demographic and clinical characteristics of included patients (n=19,850) are displayed in Table 1. The average time from symptom onset to ED presentation among patients with suspected COVID-19 was 5.4 days. In unadjusted analysis, patients with private insurance had significantly longer time of symptom onset prior to ED presentation than patients with public insurance (5.6 vs. 5.3 days, p=0.007). After multivariate adjustment, increased duration of symptoms prior to ED presentation was significantly associated with private insurance [rate ratio (RR) 1.07, 95% confidence interval (CI): 1.03 – 1.10] and no health insurance (RR 1.06, 95% CI: 1.07 – 1.13) compared to public insurance (Figure 1). Patients residing in states with Medicaid expansion were not independently associated with the increased time to ED presentation (RR 1.03, 95% CI: 1.00 – 1.07). Conclusion: Patients with private insurance or no insurance waited significantly longer to present to the ED. The extended duration of symptoms prior to presentation increases the opportunities for community transmission. The results from this study can be used by health systems to target the patients at increased risk for delayed ED presentation. [Formula presented]