Trends in COVID-19 Risk-Adjusted Mortality Rates.

Early reports showed high mortality from coronavirus disease 2019 (COVID-19). Mortality rates have recently been lower, raising hope that treatments have improved. However, patients are also now younger, with fewer comorbidities. We explored whether hospital mortality was associated with changing demographics at a 3-hospital academic health system in New York. We examined in-hospital mortality or discharge to hospice from March through August 2020, adjusted for demographic and clinical factors, including comorbidities, admission vital signs, and laboratory results. Among 5,121 hospitalizations, adjusted mortality dropped from 25.6% (95% CI, 23.2-28.1) in March to 7.6% (95% CI, 2.5-17.8) in August. The standardized mortality ratio dropped from 1.26 (95% CI, 1.15-1.39) in March to 0.38 (95% CI, 0.12-0.88) in August, at which time the average probability of death (average marginal effect) was 18.2 percentage points lower than in March. Data from one health system suggest that mortality from COVID-19 is decreasing even after accounting for patient characteristics.

The impact of COVID-19 monoclonal antibodies on clinical outcomes: A retrospective cohort study.

PURPOSE: Despite progress in the treatment of coronavirus disease 2019 (COVID-19), including the development of monoclonal antibodies (mAbs), more clinical data to support the use of mAbs in outpatients with COVID-19 is needed. This study is designed to determine the impact of bamlanivimab, bamlanivimab/etesevimab, or casirivimab/imdevimab on clinical outcomes within 30 days of COVID-19 diagnosis. METHODS: A retrospective cohort study was conducted at a single academic medical center with 3 campuses in Manhattan, Brooklyn, and Long Island, NY. Patients 12 years of age or older who tested positive for COVID-19 or were treated with a COVID-19-specific therapy, including COVID-19 mAb therapies, at the study site between November 24, 2020, and May 15, 2021, were included. The primary outcomes included rates of emergency department (ED) visit, inpatient admission, intensive care unit (ICU) admission, or death within 30 days from the date of COVID-19 diagnosis. RESULTS: A total of 1,344 mAb-treated patients were propensity matched to 1,344 patients with COVID-19 patients who were not treated with mAb therapy. Within 30 days of diagnosis, among the patients who received mAb therapy, 101 (7.5%) presented to the ED and 79 (5.9%) were admitted. Among the patients who did not receive mAb therapy, 165 (12.3%) presented to the ED and 156 (11.6%) were admitted (relative risk [RR], 0.61 [95% CI, 0.50-0.75] and 0.51 [95% CI, 0.40-0.64], respectively). Four mAb patients (0.3%) and 2.64 control patients (0.2%) were admitted to the ICU (RR, 01.51; 95% CI, 0.45-5.09). Six mAb-treated patients (0.4%) and 3.37 controls (0.3%) died and/or were admitted to hospice (RR, 1.61; 95% CI, 0.54-4.83). mAb therapy in ambulatory patients with COVID-19 decreases the risk of ED presentation and hospital admission within 30 days of diagnosis.

"I Am Not the Same as I Was Before": A Qualitative Analysis of COVID-19 Survivors.

BACKGROUND: Little is known about the illness experience of patients' long-term emotional and physical recovery from severe COVID-19 infection. This study aimed to expand upon the recovery process of COVID-19 survivors up to 6 months after hospital discharge. METHODS: Qualitative analysis of free-response answers from a cohort study of 152 patients ≥ 18 years hospitalized with laboratory-confirmed SARS-CoV-2 surveyed at 1-month post hospital discharge and 6-months post hospital discharge. Responses were analyzed with a grounded theory approach to identify overarching themes. RESULTS: Participants described persistent complications, both physical and mental, that have affected their recovery from COVID-19. Five overarching themes of post-acute patient experiences were generated: (1) an increased awareness of a mind and body connection, (2) feelings of premature aging, (3) an overall decline in quality of life, (4) a continued fear of infection, and (5) methods of coping. CONCLUSIONS: Patients described lasting changes to their mental health and overall quality of life in connection to physical complications after severe COVID-19 infection. Patients' reports of their experience call for a greater awareness of the psychological aspects of COVID-19 recovery to provide both physical and psychological rehabilitation services. Additional resources such as education around re-infection and financial resources are needed.

Evaluating the Effect of a COVID-19 Predictive Model to Facilitate Discharge: A Randomized Controlled Trial.

BACKGROUND: We previously developed and validated a predictive model to help clinicians identify hospitalized adults with coronavirus disease 2019 (COVID-19) who may be ready for discharge given their low risk of adverse events. Whether this algorithm can prompt more timely discharge for stable patients in practice is unknown. OBJECTIVES: The aim of the study is to estimate the effect of displaying risk scores on length of stay (LOS). METHODS: We integrated model output into the electronic health record (EHR) at four hospitals in one health system by displaying a green/orange/red score indicating low/moderate/high-risk in a patient list column and a larger COVID-19 summary report visible for each patient. Display of the score was pseudo-randomized 1:1 into intervention and control arms using a patient identifier passed to the model execution code. Intervention effect was assessed by comparing LOS between intervention and control groups. Adverse safety outcomes of death, hospice, and re-presentation were tested separately and as a composite indicator. We tracked adoption and sustained use through daily counts of score displays. RESULTS: Enrolling 1,010 patients from May 15, 2020 to December 7, 2020, the trial found no detectable difference in LOS. The intervention had no impact on safety indicators of death, hospice or re-presentation after discharge. The scores were displayed consistently throughout the study period but the study lacks a causally linked process measure of provider actions based on the score. Secondary analysis revealed complex dynamics in LOS temporally, by primary symptom, and hospital location. CONCLUSION: An AI-based COVID-19 risk score displayed passively to clinicians during routine care of hospitalized adults with COVID-19 was safe but had no detectable impact on LOS. Health technology challenges such as insufficient adoption, nonuniform use, and provider trust compounded with temporal factors of the COVID-19 pandemic may have contributed to the null result. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04570488.

Outcomes among Hospitalized Chronic Kidney Disease Patients with COVID-19.

Background: Patients with CKD ha ve impaired immunity, increased risk of infection-related mortality, and worsened COVID-19 outcomes. However, data comparing nondialysis CKD and ESKD are sparse. Methods: Patients with COVID-19 admitted to three hospitals in the New York area, between March 2 and August 27, 2020, were retrospectively studied using electronic health records. Patients were classified as those without CKD, those with nondialysis CKD, and those with ESKD, with outcomes including hospital mortality, ICU admission, and mortality rates. Results: Of 3905 patients, 588 (15%) had nondialysis CKD and 128 (3%) had ESKD. The nondialysis CKD and ESKD groups had a greater prevalence of comorbidities and higher admission D-dimer levels, whereas patients with ESKD had lower C-reactive protein levels at admission. ICU admission rates were similar across all three groups (23%-25%). The overall, unadjusted hospital mortality was 25%, and the mortality was 24% for those without CKD, 34% for those with nondialysis CKD, and 27% for those with ESKD. Among patients in the ICU, mortality was 56%, 64%, and 56%, respectively. Although patients with nondialysis CKD had higher odds of overall mortality versus those without CKD in univariate analysis (OR, 1.58; 95% CI, 1.31 to 1.91), this was no longer significant in fully adjusted models (OR, 1.11; 95% CI, 0.88 to 1.40). Also, ESKD status did not associate with a higher risk of mortality compared with non-CKD in adjusted analyses, but did have reduced mortality when compared with nondialysis CKD (OR, 0.57; 95% CI, 0.33 to 0.95). Mortality rates declined precipitously after the first 2 months of the pandemic, from 26% to 14%, which was reflected in all three subgroups. Conclusions: In a diverse cohort of patients with COVID-19, we observed higher crude mortality rates for patients with nondialysis CKD and, to a lesser extent, ESKD, which were not significant after risk adjustment. Moreover, patients with ESKD appear to have better outcom es than those with nondialysis CKD.

Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19.

BACKGROUND: Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with COVID-19 outside the ICU. However, there are substantial patient and operational barriers to prone positioning on acute floors. The objective of this project was to increase the frequency of prone positioning among acute care patients with COVID-19. METHODS: The researchers conducted a retrospective analysis of all adult patients admitted to the acute care floors with COVID-19 respiratory failure. A run chart was used to quantify the frequency of prone positioning over time. For the subset of patients assisted by a dedicated physical therapy team, oxygen before and after positioning was compared. The initiative consisted of four separate interventions: (1) nursing, physical therapy, physician, and patient education; (2) optimization of supply management and operations; (3) an acute care prone positioning team; and (4) electronic health record optimization. RESULTS: From March 9, 2020, to August 26, 2020, 176/875 (20.1%) patients were placed in prone position. Among these, 43 (24.4%) were placed in the prone position by the physical therapy team. Only 2/94 (2.1%) eligible patients admitted in the first two weeks of the pandemic were ever documented in prone position. After launching the initiative, weekly frequency peaked at 13/28 (46.4%). Mean oxygen saturation was 91% prior to prone positioning vs. 95.2% after (p < 0.001) in those positioned by physical therapy. CONCLUSION: A multidisciplinary quality improvement initiative increased frequency of prone positioning by proactively addressing barriers in knowledge, equipment, training, and information technology.

Validation of parsimonious prognostic models for patients infected with COVID-19.

OBJECTIVES: Predictive studies play important roles in the development of models informing care for patients with COVID-19. Our concern is that studies producing ill-performing models may lead to inappropriate clinical decision-making. Thus, our objective is to summarise and characterise performance of prognostic models for COVID-19 on external data. METHODS: We performed a validation of parsimonious prognostic models for patients with COVID-19 from a literature search for published and preprint articles. Ten models meeting inclusion criteria were either (a) externally validated with our data against the model variables and weights or (b) rebuilt using original features if no weights were provided. Nine studies had internally or externally validated models on cohorts of between 18 and 320 inpatients with COVID-19. One model used cross-validation. Our external validation cohort consisted of 4444 patients with COVID-19 hospitalised between 1 March and 27 May 2020. RESULTS: Most models failed validation when applied to our institution's data. Included studies reported an average validation area under the receiver-operator curve (AUROC) of 0.828. Models applied with reported features averaged an AUROC of 0.66 when validated on our data. Models rebuilt with the same features averaged an AUROC of 0.755 when validated on our data. In both cases, models did not validate against their studies' reported AUROC values. DISCUSSION: Published and preprint prognostic models for patients infected with COVID-19 performed substantially worse when applied to external data. Further inquiry is required to elucidate mechanisms underlying performance deviations. CONCLUSIONS: Clinicians should employ caution when applying models for clinical prediction without careful validation on local data.

Six-Month Outcomes in Patients Hospitalized with Severe COVID-19.

BACKGROUND: Previous work has demonstrated that patients experience functional decline at 1-3 months post-discharge after COVID-19 hospitalization. OBJECTIVE: To determine whether symptoms persist further or improve over time, we followed patients discharged after hospitalization for severe COVID-19 to characterize their overall health status and their physical and mental health at 6 months post-hospital discharge. DESIGN: Prospective observational cohort study. PARTICIPANTS: Patients ≥ 18 years hospitalized for COVID-19 at a single health system, who required at minimum 6 l of supplemental oxygen during admission, had intact baseline functional status, and were discharged alive. MAIN MEASURES: Overall health status, physical health, mental health, and dyspnea were assessed with validated surveys: the PROMIS® Global Health-10 and PROMIS® Dyspnea Characteristics instruments. KEY RESULTS: Of 152 patients who completed the 1 month post-discharge survey, 126 (83%) completed the 6-month survey. Median age of 6-month respondents was 62; 40% were female. Ninety-three (74%) patients reported that their health had not returned to baseline at 6 months, and endorsed a mean of 7.1 symptoms. Participants' summary t-scores in both the physical health and mental health domains at 6 months (45.2, standard deviation [SD] 9.8; 47.4, SD 9.8, respectively) remained lower than their baseline (physical health 53.7, SD 9.4; mental health 54.2, SD 8.0; p<0.001). Overall, 79 (63%) patients reported shortness of breath within the prior week (median score 2 out of 10 (interquartile range [IQR] 0-5), vs 42 (33%) pre-COVID-19 infection (0, IQR 0-1)). A total of 11/124 (9%) patients without pre-COVID oxygen requirements still needed oxygen 6 months post-hospital discharge. One hundred and seven (85%) were still experiencing fatigue at 6 months post-discharge. CONCLUSIONS: Even 6 months after hospital discharge, the majority of patients report that their health has not returned to normal. Support and treatments to return these patients back to their pre-COVID baseline are urgently needed.

Decreasing Incidence of Acute Kidney Injury in Patients with COVID-19 Critical Illness in New York City.

INTRODUCTION: Reports from the United States suggest that acute kidney injury (AKI) frequently complicates coronavirus disease 2019 (COVID-19), but understanding of AKI risks and outcomes is incomplete. In addition, whether kidney outcomes have evolved during the course of the pandemic is unknown. METHODS: We used electronic medical records to identify patients with COVID-19 with and without AKI admitted to 3 New York Hospitals between March 2 and August 25, 2020. Outcomes included AKI overall and according to admission week, AKI stage, the requirement for new renal replacement therapy (RRT), mortality, and recovery of kidney function. Logistic regression was used to assess associations of patient characteristics and outcomes. RESULTS: Of 4732 admissions, 1386 (29.3%) patients had AKI. Among those with AKI, 717 (51.7%) had stage 1 disease, 132 (9.5%) had stage 2 disease, 537 (38.7%) had stage 3 disease, and 237 (17.1%) required RRT initiation. In March, 536 of 1648 (32.5%) patients developed AKI compared with 15 of 87 (17.2%) in August (P < 0.001 for monthly trend), whereas RRT initiation was required in 6.9% and 0% of admissions in March and August, respectively. Mortality was higher with than without AKI (51.6% vs. 8.6%) and was 71.9% in individuals requiring RRT. However, most patients with AKI who survived hospitalization (77%) recovered to within 0.3 mg/dl of baseline creatinine. Among those surviving to discharge, 62% discontinued RRT. CONCLUSIONS: AKI impacts a high proportion of admitted patients with COVID-19 and is associated with high mortality, particularly when RRT is required. AKI incidence appears to be decreasing over time and kidney function frequently recovers in those who survive.

Pulmonary Embolism at CT Pulmonary Angiography in Patients with COVID-19.

PURPOSE: To evaluate pulmonary embolism (PE) prevalence at CT pulmonary angiography in patients testing positive for coronavirus disease 2019 (COVID-19) and factors associated with PE severity. MATERIALS AND METHODS: A retrospective, single-center study evaluated 62 patients who tested positive for COVID-19 who underwent CT pulmonary angiography between March 13 and April 5, 2020. Another 62-patient cohort who underwent CT pulmonary angiography before the first reported local COVID-19 case was retrospectively selected. The relative rate of CT pulmonary angiography positivity was recorded. For the COVID-19 positive cohort, comorbidities, laboratory values, clinical outcome, and venous thrombosis of the patients were recorded. Two thoracic radiologists assessed embolic severity using the Mastora system and evaluated right heart strain. Factors associated with PE and arterial obstruction severity were evaluated by using statistical analysis. A P value < .05 was considered significant. RESULTS: Of the patients testing positive for COVID-19, 37.1% had PE, higher than 14.5% of pre-COVID-19 patients (P = .007). d-dimer levels closest to CT pulmonary angiography date correlated with the Mastora obstruction score. Receiver operating characteristic analysis identified optimal sensitivity (95%) and specificity (71%) for PE diagnosis at 1394 ng/mL d-dimer units. The mean d-dimer level was 1774 ng/mL and 6432 ng/mL d-dimer units in CT pulmonary angiography-negative and CT pulmonary angiography-positive subgroups, respectively (P < .001). One additional patient with negative results at CT pulmonary angiography had deep venous thrombosis, thus resulting in 38.7% with PE or deep venous thrombosis, despite 40% receiving prophylactic anticoagulation. Other factors did not demonstrate significant PE association. CONCLUSION: A total of 37.1% of COVID-19 patients underwent CT pulmonary angiographic examinations diagnosing PE. PE can be a cause of decompensation in patients testing positive for COVID-19, and d-dimer can be used to stratify patients in terms of PE risk and severity.Supplemental material is available for this article.© RSNA, 2020.

Trends in Risk-Adjusted 28-Day Mortality Rates for Patients Hospitalized with COVID-19 in England.

Early reports showed high mortality from coronavirus disease 2019 (COVID-19). Mortality rates have recently been lower; however, patients are also now younger, with fewer comorbidities. We explored 28-day mortality for patients hospitalized for COVID-19 in England over a 5-month period, adjusting for a range of potentially mitigating variables, including sociodemographics and comorbidities. Among 102,610 hospitalizations, crude mortality decreased from 33.4% (95% CI, 32.9-34.0) in March 2020 to 15.5% (95% CI, 14.1-17.0) in July. Adjusted mortality decreased from 33.4% (95% CI, 32.8-34.1) in March to 17.4% (95% CI, 11.3-26.9) in July. The relative risk of mortality decreased from a reference of 1 in March to 0.52 (95% CI, 0.34-0.80) in July. This demonstrates that the reduction in mortality is not solely due to changes in the demographics of those with COVID-19.

Post-Discharge Health Status and Symptoms in Patients with Severe COVID-19.

BACKGROUND: Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS: This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS: A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS: Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.

A validated, real-time prediction model for favorable outcomes in hospitalized COVID-19 patients.

The COVID-19 pandemic has challenged front-line clinical decision-making, leading to numerous published prognostic tools. However, few models have been prospectively validated and none report implementation in practice. Here, we use 3345 retrospective and 474 prospective hospitalizations to develop and validate a parsimonious model to identify patients with favorable outcomes within 96 h of a prediction, based on real-time lab values, vital signs, and oxygen support variables. In retrospective and prospective validation, the model achieves high average precision (88.6% 95% CI: [88.4-88.7] and 90.8% [90.8-90.8]) and discrimination (95.1% [95.1-95.2] and 86.8% [86.8-86.9]) respectively. We implemented and integrated the model into the EHR, achieving a positive predictive value of 93.3% with 41% sensitivity. Preliminary results suggest clinicians are adopting these scores into their clinical workflows.

Prevalence and Outcomes of D-Dimer Elevation in Hospitalized Patients With COVID-19.

OBJECTIVE: To determine the prevalence of D-dimer elevation in coronavirus disease 2019 (COVID-19) hospitalization, trajectory of D-dimer levels during hospitalization, and its association with clinical outcomes. Approach and Results: Consecutive adults admitted to a large New York City hospital system with a positive polymerase chain reaction test for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) between March 1, 2020 and April 8, 2020 were identified. Elevated D-dimer was defined by the laboratory-specific upper limit of normal (>230 ng/mL). Outcomes included critical illness (intensive care, mechanical ventilation, discharge to hospice, or death), thrombotic events, acute kidney injury, and death during admission. Among 2377 adults hospitalized with COVID-19 and ≥1 D-dimer measurement, 1823 (76%) had elevated D-dimer at presentation. Patients with elevated presenting baseline D-dimer were more likely than those with normal D-dimer to have critical illness (43.9% versus 18.5%; adjusted odds ratio, 2.4 [95% CI, 1.9-3.1]; P<0.001), any thrombotic event (19.4% versus 10.2%; adjusted odds ratio, 1.9 [95% CI, 1.4-2.6]; P<0.001), acute kidney injury (42.4% versus 19.0%; adjusted odds ratio, 2.4 [95% CI, 1.9-3.1]; P<0.001), and death (29.9% versus 10.8%; adjusted odds ratio, 2.1 [95% CI, 1.6-2.9]; P<0.001). Rates of adverse events increased with the magnitude of D-dimer elevation; individuals with presenting D-dimer >2000 ng/mL had the highest risk of critical illness (66%), thrombotic event (37.8%), acute kidney injury (58.3%), and death (47%). CONCLUSIONS: Abnormal D-dimer was frequently observed at admission with COVID-19 and was associated with higher incidence of critical illness, thrombotic events, acute kidney injury, and death. The optimal management of patients with elevated D-dimer in COVID-19 requires further study.

Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study.

OBJECTIVE: To describe outcomes of people admitted to hospital with coronavirus disease 2019 (covid-19) in the United States, and the clinical and laboratory characteristics associated with severity of illness. DESIGN: Prospective cohort study. SETTING: Single academic medical center in New York City and Long Island. PARTICIPANTS: 5279 patients with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection between 1 March 2020 and 8 April 2020. The final date of follow up was 5 May 2020. MAIN OUTCOME MEASURES: Outcomes were admission to hospital, critical illness (intensive care, mechanical ventilation, discharge to hospice care, or death), and discharge to hospice care or death. Predictors included patient characteristics, medical history, vital signs, and laboratory results. Multivariable logistic regression was conducted to identify risk factors for adverse outcomes, and competing risk survival analysis for mortality. RESULTS: Of 11 544 people tested for SARS-Cov-2, 5566 (48.2%) were positive. After exclusions, 5279 were included. 2741 of these 5279 (51.9%) were admitted to hospital, of whom 1904 (69.5%) were discharged alive without hospice care and 665 (24.3%) were discharged to hospice care or died. Of 647 (23.6%) patients requiring mechanical ventilation, 391 (60.4%) died and 170 (26.2%) were extubated or discharged. The strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% confidence interval 26.1 to 56.0) for ages 75 years and older. Other risks were heart failure (4.4, 2.6 to 8.0), male sex (2.8, 2.4 to 3.2), chronic kidney disease (2.6, 1.9 to 3.6), and any increase in body mass index (BMI) (eg, for BMI >40: 2.5, 1.8 to 3.4). The strongest risks for critical illness besides age were associated with heart failure (1.9, 1.4 to 2.5), BMI >40 (1.5, 1.0 to 2.2), and male sex (1.5, 1.3 to 1.8). Admission oxygen saturation of <88% (3.7, 2.8 to 4.8), troponin level >1 (4.8, 2.1 to 10.9), C reactive protein level >200 (5.1, 2.8 to 9.2), and D-dimer level >2500 (3.9, 2.6 to 6.0) were, however, more strongly associated with critical illness than age or comorbidities. Risk of critical illness decreased significantly over the study period. Similar associations were found for mortality alone. CONCLUSIONS: Age and comorbidities were found to be strong predictors of hospital admission and to a lesser extent of critical illness and mortality in people with covid-19; however, impairment of oxygen on admission and markers of inflammation were most strongly associated with critical illness and mortality. Outcomes seem to be improving over time, potentially suggesting improvements in care.