Remdesivir, Survival, Length of Hospital Stay in Veterans With COVID-19

Quick Takes

  • This cohort study of US veterans hospitalized with COVID-19 at Veterans Affairs facilities, reports that remdesivir treatment was associated with prolonged hospitalization without improved survival.
  • It is possible that clinicians were not discharging patients who otherwise met the criteria for hospital discharge until the remdesivir course was completed and may explain the extended hospital stay.
  • Of note, the protocol of the trial used for remdesivir authorization called for infusions to be stopped early if the patient met the primary outcome and ready to be discharged, but this detail may not have been adequately communicated to clinicians.

Study Questions:

What are the associations between remdesivir treatment and survival and length of hospital stay among people hospitalized with coronavirus disease 2019 (COVID-19) in routine care settings?

Methods:

The investigators conducted a retrospective cohort study using data from the Veterans Health Administration (VHA) to identify adult patients in 123 VHA hospitals who had a hospitalization with laboratory-confirmed COVID-19 from May 1 to October 8, 2020. Propensity score matching of patients initiating remdesivir treatment to control patients who had not initiated remdesivir treatment by the same hospital day was used to create the analytic cohort. The main outcomes and measures were time to death within 30 days of remdesivir treatment initiation (or corresponding hospital day for matched control individuals) and time to hospital discharge with time to death as a competing event. Associations between remdesivir treatment and these outcomes were assessed using Cox proportional hazards regression in the matched cohort.

Results:

The initial cohort included 5,898 patients admitted to 123 hospitals, 2,374 (40.3%) of whom received remdesivir treatment (2,238 men [94.3%]; mean [SD] age, 67.8 [12.8] years) and 3,524 (59.7%) of whom never received remdesivir treatment (3,302 men [93.7%]; mean [SD] age, 67.0 [14.4] years). After propensity score matching, the analysis included 1,172 remdesivir recipients and 1,172 controls, for a final matched cohort of 2,344 individuals. Remdesivir recipients and matched controls were similar with regard to age (mean [SD], 66.6 [14.2] years vs. 67.5 [14.1] years), sex (1,101 men [93.9%] vs. 1,101 men [93.9%]), dexamethasone use (559 [47.7%] vs. 559 [47.7%]), admission to the intensive care unit (242 [20.7%] vs. 234 [19.1%]), and mechanical ventilation use (69 [5.9%] vs. 45 [3.8%]). Standardized differences were <10% for all measures. Remdesivir treatment was not associated with 30-day mortality (143 remdesivir recipients [12.2%] vs. 124 controls [10.6%]; log rank p = 0.26; adjusted hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.83-1.36). Results were similar for people receiving versus not receiving dexamethasone at remdesivir initiation (dexamethasone recipients: adjusted HR, 0.93; 95% CI, 0.64-1.35; nonrecipients: adjusted HR, 1.19; 95% CI, 0.84-1.69). Remdesivir recipients had a longer median time to hospital discharge compared with matched controls (6 days [interquartile range, 4-12 days] vs. 3 days [interquartile range, 1-7 days]; p < 0.001).

Conclusions:

The authors concluded that remdesivir treatment was not associated with improved survival but was associated with longer hospital stays in this cohort study of US veterans hospitalized with COVID-19.

Perspective:

This cohort study of US veterans hospitalized with COVID-19 at Veterans Affairs facilities, reports that remdesivir treatment was associated with prolonged hospitalization without improved survival. The finding of a longer time to hospital discharge with remdesivir treatment represents a potential unintended and undesirable consequence of remdesivir adoption in practice. It is possible that clinicians were not discharging patients who otherwise met the criteria for hospital discharge until the remdesivir course was completed and may explain the extended hospital stay. Of note, the protocol of the trial used for remdesivir authorization called for infusions to be stopped early if the patient met the primary outcome of the study and ready to be discharged, but this detail may not have been adequately communicated to the clinicians.

Clinical Topics: Prevention

Keywords: Coronavirus, COVID-19, Dexamethasone, Hospitalization, Length of Stay, Patient Admission, Patient Discharge, Primary Prevention, remdesivir, Respiration, Artificial, Survival, Treatment Outcome, Veterans


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