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Factors Associated With Death in Critically Ill Patients With COVID-19
Quick Takes
- In a cohort of >2,200 patients with COVID-19 who were admitted to ICUs at 65 geographically diverse sites in the United States, 35% died within 28 days, with wide variation observed among hospitals.
- Factors associated with death included older age, male sex, obesity, coronary artery disease, cancer, acute organ dysfunction, and admission to a hospital with fewer ICU beds.
- This study identified demographic-, clinical-, and hospital-level factors associated with death in critically ill patients with COVID-19 that may be used to facilitate the identification of favorable therapeutic interventions.
Study Questions:
What are the characteristics, outcomes, and factors associated with death among critically ill patients with coronavirus disease 2019 (COVID-19) in the United States?
Methods:
This multicenter cohort study assessed 2,215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the United States from March 4 to April 4, 2020. Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including the number of ICU beds, were extracted. 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 2,215 patients (mean age 60.5 years; 64.8% men; 78.5% with ≥1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 35.4% had died, 37.2% had been discharged, and 27.4% remained hospitalized. Factors independently associated with death included older age, male sex, higher body mass index, coronary artery disease, active cancer, presence of hypoxemia, liver dysfunction, and kidney dysfunction at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs. >100 ICU beds: odds ratio, 3.28; 95% confidence interval, 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 adjunctive treatments and supportive therapies.
Conclusions:
In this multicenter cohort study of critically ill adults with COVID-19 in the United States, more than one in three died within 28 days after ICU admission. The authors identified several patient- and hospital-level factors that were associated with death and found that treatment and outcomes varied considerably among hospitals.
Perspective:
The COVID-19 pandemic has had devastating morbidity and mortality, with >3.68 million cases and >141,000 deaths in the United States alone (as of July 17, 2020). STOP-COVID (Study of the Treatment and Outcomes in Critically Ill Patients With COVID-19) is an extensive multicenter cohort study examining demographics, comorbidities, organ dysfunction, treatment, and outcomes of patients with COVID-19 admitted to ICUs across the United States. This study has several strengths, building upon prior studies on critical illness from COVID-19 cohorts in China, Italy, and small case series from the United States. In particular, this study examined data from primary medical record review (as opposed to administrative data or billing records), included a large number of geographically diverse hospitals from across the United States, and provided longitudinal follow-up to 28 days in the primary analysis. The authors appropriately acknowledge several limitations, including unmeasured differences in patient populations among hospitals, residual confounding due to lack of socioeconomic data, and lack of data on ventilator management strategies, hospital or ICU patient volume, physician and nurse availability, or varying degrees of strain on available resources across hospitals, including ICU bed capacity. Future research should examine which therapeutic interventions may be most effective for critically ill patients with COVID-19 at greatest risk of adverse outcomes. These investigations will help inform decision making about appropriate therapies, resource allocation, hospital and critical care capacity, and medical supply and distribution chains.
Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Prevention, Atherosclerotic Disease (CAD/PAD), Novel Agents, Statins
Keywords: Body Mass Index, Coronary Artery Disease, Coronavirus, COVID-19, Critical Illness, Hospital Mortality, Hydroxychloroquine, Intensive Care Units, Multiple Organ Failure, Neoplasms, Obesity, Patient Discharge, Primary Prevention, severe acute respiratory syndrome coronavirus 2
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