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Risk Factors of In-Hospital Mortality Among US COVID-19 Patients
Quick Takes
- In a retrospective database review of nearly 65,000 patients with COVID-19 across 592 hospitals in the United States, the in-hospital mortality was >20% and severe complications were common.
- Use of statins, ACE inhibitors, calcium channel blockers, and vitamin C or D supplements was associated with decreased odds of in-hospital mortality.
- The combination of azithromycin and hydroxychloroquine was associated with increased odds of in-hospital mortality.
Study Questions:
What are the demographics, clinical characteristics, treatment patterns, and risk factors associated with mortality in patients with coronavirus disease 2019 (COVID-19) across all regions of the United States?
Methods:
A retrospective review was performed of the largest administrative discharge database in the United States, containing information from both inpatient and outpatient hospital-based visits from 592 acute care hospitals across the United States. Patients with a diagnosis of COVID-19 between April 1 and May 31 were included. Demographic characteristics as well as hospital characteristics were obtained. Clinical characteristics obtained included comorbidities, as well as COVID-related complications. Common medications and supplements were obtained as well. Outcome measures were in-hospital mortality, intensive care unit (ICU) admission, use of invasive mechanical respiratory support, acute complications, treatment patterns, and total length of stay (LOS).
Results:
Overall, 64,781 patients with COVID-19 were analyzed, of whom 45.5% were outpatients (median age 46 years, interquartile range [IQR] 33-59) and 54.5% were inpatients (median age 65 years, IQR 52-77); 49% were male, 40% White, and 22% Black. In the overall patient sample, the most common acute complications were respiratory failure (31%), renal failure (18%), and sepsis (19%).
Among inpatients, 11% had shock, 8% had acute respiratory distress syndrome, 8% had acute ischemic heart disease, and 4% had venous thromboembolism. Approximately 34% of inpatients were given the combination of hydroxychloroquine and azithromycin, 35% corticosteroids, and 24% vitamin C or D. Mortality rate was 11.4% overall (7,355 of 64,781) and 20% for inpatients (7,164 of 35,302). 19% of inpatients required ICU care and 16% received invasive mechanical ventilation. Multivariable logistic regression showed that the risk factor most strongly associated with death was age, with an odds ratio (OR) of 16.2 for inpatients aged ≥80 years compared to those aged 18-34 years. Patients from hospitals located in the Northeast had greater risk of death than those in the Midwest (OR, 1.59; 95% confidence interval [CI], 1.44-1.76).
Among cardiovascular medications, statins (OR, 0.60; 95% CI, 0.56-0.65), angiotensin-converting enzyme (ACE) inhibitors (OR, 0.53; 95% CI, 0.46-0.60), and calcium channel blockers (OR, 0.73; 95% CI, 0.68-0.79) were associated with decreased odds of death. Vitamin C and D supplements were also associated with decreased odds of death (OR, 0.89; 95% CI 0.82-0.97). Patients who received a combination of azithromycin and hydroxychloroquine had slightly increased odds of death (OR, 1.2; 95% CI, 1.11-1.31) as compared to those who received neither drug.
Conclusions:
In this retrospective study of 64,781 patients with COVID-19 treated in 592 hospitals across the United States in April and May 2020, in-patient mortality was 20.3%, and ICU admission and severe complications (sepsis, acute kidney failure, and need for mechanical ventilation) were common. Use of statins, ACE inhibitors, calcium channel blockers, and vitamin C or D, were associated with decreased odds of mortality, while the combination of hydroxychloroquine and azithromycin was associated with increased odds of mortality.
Perspective:
This large administrative database review provides important epidemiologic and outcomes data from nearly 65,000 COVID-19 patients from the first wave of the global pandemic. The associations identified in the study (e.g., between the use of various drug classes and mortality) are limited due to the lack of clinical detail. For example, duration, dosing, and timing of cardiovascular medications or vitamin supplements cannot be determined. Likewise, association of a given therapy with improved clinical outcomes could be a marker of enhanced accessibility to care or a correlate of socioeconomic status or more effective management of comorbid illness. As such, the results would be of use primarily in hypothesis generation or as confirmation of interventional trials.
Clinical Topics: COVID-19 Hub, Dyslipidemia, Prevention, Nonstatins, Novel Agents, Statins
Keywords: Acute Kidney Injury, Angiotensin-Converting Enzyme Inhibitors, Azithromycin, Calcium Channel Blockers, Coronavirus, COVID-19, Hospital Mortality, Hydroxychloroquine, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Inpatients, Peptidyl-Dipeptidase A, Primary Prevention, Respiratory Distress Syndrome, Renal Insufficiency, Respiration, Artificial, Respiratory Insufficiency, Risk Factors, Sepsis, Shock, Ventilation, Vitamin D
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