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Patient Trajectories Among COVID-19 Hospitalized Patients
Quick Takes
- The authors report an analysis of the clinical features, patient trajectories, and risk factors for progression to severe disease or death at the time of hospital admission among all patients admitted to Johns Hopkins health system.
- The data are used to develop the COVID-19 Inpatient Risk Calculator (CIRC) to quantify the probability of progression to severe disease or death among patients hospitalized with COVID-19.
Study Questions:
What factors available at the time of hospital admission predict outcome trajectories (i.e., severe disease or death) in patients with coronavirus disease 2019 (COVID-19)?
Methods:
The authors performed a retrospective cohort analysis of five hospitals in the Maryland and Washington, DC, area within the Johns Hopkins Medicine health care system, examining 832 consecutive COVID-19 admissions from March 4, 2020 to April 24, 2020, with follow-up through June 27, 2020. The primary data source was JH-CROWN: The COVID-19 PMAP Registry, which utilizes the Hopkins Precision Medicine Analytics Platform. Primary outcomes were death and a composite of severe disease or death, defined using the World Health Organization COVID-19 disease severity scale, an 8-point ordinal scale ranging from ambulatory (1 = asymptomatic) to death (score of 8). To assess the association between patient characteristics at admission and outcomes, a set of 24 demographic and clinical variables were selected on the basis of their clinical relevance. Multiple comorbid condition burden was assessed by using the 17-item modified Charlson Comorbidity Index.
Results:
During the study period, 832 patients were admitted with COVID-19. Among all patients, 131 (16%) died (66 [50%] were nursing home residents) and 694 (83%) were discharged (523 [63%] had mild to moderate disease and 171 [20%] had severe disease). Median patient age was 63 years (range, 1-108 years); 47% were women; 41% were Black; 16% were Latino; and 21% were nursing home residents. Of 787 patients admitted with mild to moderate disease, 302 (38%) progressed to severe disease or death: 181 (60%) by day 2 and 238 (79%) by day 4. Patients had very different probabilities of disease progression on the basis of age, nursing home residence, comorbid conditions, obesity, respiratory symptoms, respiratory rate, fever, absolute lymphocyte count, hypoalbuminemia, troponin level, C-reactive protein, and interaction among these factors. Using only factors present on admission, a model to predict in-hospital disease progression had an area under the curve of 0.85, 0.79, and 0.79, at day 2, 4, and 7, respectively.
Conclusions:
A combination of demographic and clinical variables is strongly associated with severe COVID-19 disease or death and their early onset. The COVID-19 Inpatient Risk Calculator (CIRC), using factors present on admission, can inform clinical and resource allocation decisions.
Perspective:
This retrospective study provides further insight into the disease trajectories of hospitalized patients with COVID-19 in the United States as well as risk factors associated with severe outcomes and death. Older age, nursing home residence, and obesity were associated with a high risk for death (as seen in prior reports). The CIRC may be a useful instrument for risk prognostication and performed best at predicting progression to severe disease or death in the first 2 days of hospital admission. Study limitations include generalizability due to the single health care system and underascertainment due to testing availability and atypical symptoms (including loss of taste or smell). Nonetheless, this is a potentially important contribution to our rapidly evolving literature on COVID-19.
Clinical Topics: COVID-19 Hub, Prevention
Keywords: Comorbidity, Coronavirus, COVID-19, C-Reactive Protein, Hypoalbuminemia, Inpatients, Nursing Homes, Obesity, Primary Prevention, Respiratory Tract Infections, Risk Factors, Troponin
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