ABSTRACT
Background. While COVID-19 carries substantial morbidity and mortality, the extent of long-term complications remains unclear. Reports suggest that acute lung damage associated with severe COVID-19 can result in chronic respiratory dysfunction. This study: (1) estimated the incidence of dyspnea and ILD after COVID-19 hospitalization, and (2) assessed risk factors for developing dyspnea and ILD in a real-world cohort of patients hospitalized with COVID-19 using US electronic health records (EHR). Methods. Patients in the Optum de-identified COVID-19 EHR database who were hospitalized for COVID-19 (lab confirmed or diagnosis code) between February 20 and July 2020 and had at least 6 months of follow-up were eligible for analysis. Dyspnea and ILD were identified using diagnosis codes. The effects of baseline characteristics and hospitalization factors on the risk of incident dyspnea or ILD 3 to 6 months' post discharge were evaluated. Results. Among eligible patients (n=26,339), 1705 (6.5%) had dyspnea and 220 (0.8%) had ILD 3 to 6 months after discharge. Among patients without prior dyspnea or ILD (n=22,613), 110 (0.5%) had incident ILD (Table 1) and 1036 (4.6%) had incident dyspnea (Table 2) 3 to 6 months after discharge. In multivariate analyses, median (IQR) length of stay (LOS;5.0 [3.0, 9.0] days in patients who did not develop ILD vs 14.5 [6.0, 26.0] days in patients who developed ILD;RR: 1.12, 95% CI: 1.08, 1.15;P=4.34 x 10-10) and age (RR: 1.02, 95% CI: 1.01, 1.03;P=4.63 x 10-3) were significantly associated with ILD. Median (IQR) LOS (5.0 [3.0, 9.0] days in patients who did not develop dyspnea vs 7 [4.0, 14.0] days in patients who developed dyspnea;RR: 1.04, 95% CI: 1.02, 1.06;P=8.52 x 10-4), number of high-risk comorbidities (RR: 1.18, 95% CI: 1.12, 1.24;P=3.85 x 10-9), and obesity (RR: 1.52, 95% CI: 1.25, 1.86;P=2.59 x 10-4) were significantly associated with dyspnea. Conclusion. In a real-world cohort, 4.6% and 0.5% of patients developed dyspnea and ILD, respectively, after COVID-19 hospitalization. Multivariate analyses suggested that LOS, age, obesity, and comorbidity burden may be risk factors for post-COVID-19 respiratory complications. Limitations included sensitivity of diagnosis codes, availability of labs, and care-seeking bias.
ABSTRACT
Background. Over 29 million people have been infected with COVID-19 in the U.S. alone. While COVID-19 carries serious morbidity and mortality, potential for co-infection with other respiratory infections remains unclear. We aimed to: (1) estimate co-infection prevalence of COVID-19 and influenza, and (2) compare demographics and clinical outcomes of co-infected patients to those of COVID-19 singly-infected patients using U.S. electronic health records (EHR). Methods. Patients in the Optum De-identified COVID-19 EHR database diagnosed with COVID-19 (lab-confirmed or ICD code) between February 2020 and January 2021 were eligible. Influenza co-infection was defined as an influenza diagnosis (lab-confirmed or ICD code) within ±10 days of COVID-19 diagnosis. We report co-infection prevalence for all COVID-19 patients and for a subset of hospitalized COVID-19 patients. Results. Among all COVID-19 patients (N = 549,532), 1,794 (0.3%) were co-infected with influenza. Among the hospitalized subset (N = 80,192), 242 (0.3%) were co-infected with influenza. In sensitivity analyses restricting to lab-confirmed influenza, co-infection prevalence was 0.1% overall and 0.2% among hospitalized patients. No meaningful differences were observed in baseline demographics between co-infected and singly-infected patients. Among hospitalized patients, univariate analysis suggested higher likelihood of invasive ventilation (12.8% vs. 9.8%;p=0.14), respiratory failure (56.2% vs. 46.6%, p< 0.01), and ICU stay (27.3% vs. 23.1%, p=0.13), but no meaningful difference in mortality (13.3% vs. 13.0%, p=0.97), for co-infected as compared to singly-infected COVID-19 patients. Conclusion. In a real-world cohort, we observed a low proportion (0.3%) of COVID-19 patients co-infected with influenza. Co-infected patients had similar baseline characteristics but higher likelihood of hospitalization severity as compared to singly-infected COVID-19 patients. Limitations include low prevalence of circulating influenza and potential missing data bias.
ABSTRACT
Background. Over 32 million cases of COVID-19 have been reported in the US. Outcomes range from mild upper respiratory infection to hospitalization, acute respiratory failure, and death. We assessed risk factors associated with severe disease, defined as hospitalization within 21 days of diagnosis or death, using US electronic health records (EHR). Methods. Patients in the Optum de-identified COVID-19 EHR database who were diagnosed with COVID-19 in 2020 were included in the analysis. Regularized multivariable logistic regression was used to identify risk factors for severe disease. Covariates included demographics, comorbidities, history of influenza vaccination, and calendar time. Results. Of the 193,454 eligible patients, 36,043 (18.6%) were hospitalized within 21 days of COVID-19 diagnosis, and 6,397 (3.3%) died. Calendar time followed an inverse J-shaped relationship where severe disease rates rapidly declined in the first 25 weeks of the pandemic. BMI followed an asymmetric V-shaped relationship with highest rates of disease severity observed at the extremes. In the multivariable model, older age had the strongest association with disease severity (odds ratios and 95% confidence intervals of significant associations in Figure). Other risk factors were male sex, uninsured status, underweight and obese BMI, higher Charlson Comorbidity Index, and individual comorbidities including hypertension. Asthma and overweight BMI were not associated with disease severity. Blacks, Hispanics, and Asians experienced higher odds of disease severity compared to Whites. Conclusion. Odds of hospitalization or death have decreased since the start of the pandemic, with the steepest decline observed up to mid-August, possibly reflecting changes in both testing and treatment. Older age is the most important predictor of severe COVID-19. Obese and underweight, but not overweight, BMI were associated with increased odds of disease severity when compared to normal weight. Hypertension, despite not being included in many guidelines for vaccine prioritization, is a significant risk factor. Pronounced health disparities remain across race and ethnicity after accounting for comorbidities, with minorities experiencing higher disease severity.
ABSTRACT
Background. COVID-19 remains a threat to public health, with over 30 million cases in the US alone. As understanding of optimal patient care has improved, treatment guidelines have continued to evolve. This study characterized real-world trends in treatment for US patients hospitalized with COVID-19, stratified by whether patients required invasive ventilation. Methods. US patients diagnosed and hospitalized with COVID-19 between March 23 and December 31, 2020, in the Optum de-identified COVID-19 electronic health record (EHR) data set were identified. Both drug and procedure codes were used to ascertain medications, and both procedure and diagnostic codes were used to detect invasive ventilation during hospitalization. Medication trends were estimated by computing proportions of hospitalized patients receiving each drug weekly during the study period. Results. In this cohort of 71,366 hospitalized patients, the largest observed change in care was related to chloroquine/hydroxychloroquine (HCQ) (Figure). HCQ usage peaked at 87% of patients receiving invasive ventilation (54% without ventilation) in the first week of this study (March 23-29), but declined to < 5% of patients, regardless of ventilation status, by the end of May. In contrast, dexamethasone usage was 10% at baseline in patients receiving ventilation (1% without ventilation) and increased to a steady state of >85% of patients receiving ventilation ( >50% without ventilation) by the end of June. Similarly, remdesivir usage increased sharply from a baseline of 2% of patients and continued to rise to a peak of 79% of patients receiving invasive ventilation (44% without ventilation) in November before declining. Conclusion. Meaningful shifts in treatments for US patients hospitalized with COVID-19 were observed from March through December 2020. A dramatic decline was observed for HCQ use, likely owing to safety concerns, while usage of dexamethasone and remdesivir increased as evidence of their efficacy mounted. Across medications, usage was substantially more prevalent among patients requiring invasive ventilation compared with patients with less severe cases.
ABSTRACT
Introduction: On 11 March 2020, the World Health Organization declared COVID-19 a pandemic. The effects of the pandemic on healthcare are still being described. Understanding these effects is especially important for people living with multiple sclerosis (PLwMS), who may have higher COVID-19 risks due to the use of immunosuppressive therapies and concomitant disability. Aims: To describe the impact of the COVID-19 pandemic on healthcare for PLwMS in the US. Methods: Adults with MS were recruited to the FlywheelMS study from across the US. Supervised machine learning with human curation was used to retrieve, digitise and abstract medical records, which were collected as far back as available. We compared healthcare interactions, assessments and disease-modifying therapies (DMTs) in the 6 months before and after 11 March 2020, from a constant cohort of patients. Results: Among the eligible cohort (N=1,485), total healthcare interactions were down 16.1% [15.3-17.0], (n=7,612, p<0.001) during the pandemic, a trend fuelled by declines in neurology (-19.5% [17.5-21.5], n=1,598, p<0.001) and physical therapy (-15.5% [11.6-19.4], n=384, p=0.002) visits. Telehealth interactions increased (+10.3% [1.4-17.3], n=68, p=0.02) though few interactions were conducted this way. The frequency of clinical and imaging assessments such as MRI (-43.7% [40.9-46.5], n=281, p<0.001), Expanded Disability Status Scale (-37.7% [29.1-46.2], n=146, p<0.001) and Timed 25-Foot Walk Test (-58.2% [52.1-64.3], n=280, p<0.001) declined substantially during the pandemic. DMT initiations also decreased markedly, with declines of at least 50% across platform (-50% [23.1-76.9], n=20, p=0.001), oral (-56.6% [44.1-69.0], n=76, p<0.001) and infusion (-58.4% [47.1-69.8], n=89, p<0.001) therapies. Finally, health record capture of mild relapses (those not requiring hospitalisation) was down 24.2% [17.7-30.8] in the pandemic period (n=194, p<0.001), while capture of severe relapses requiring hospitalisation remained constant (-3.3% [-8.1-1.5], n=91, p=0.75). Conclusions: Healthcare interactions, assessments and DMT initiations all declined for PLwMS in the US during the COVID-19 pandemic. Additionally, healthcare record capture for mild relapses, but not severe relapses, declined. These findings suggest patients and providers are deferring MS healthcare during the pandemic.