3219 hospitalized patients with COVID-19 in Southeast Michigan: a retrospective case-cohort study

3219 hospitalized patients with COVID-19 in Southeast Michigan: a retrospective case-cohort study

Methods

This study was conducted at an eight-hospital health system in Southeast Michigan. Southeast Michigan is the metro area of Detroit and is home to 4.5 million people, almost half of the population of the state of Michigan. Patients were included in the study if they tested positive for SARS-CoV-2 infection by nasopharyngeal PCR test and were admitted to one of the eight hospitals between 13 March 2020 and 29 April 2020. Data were collected retrospectively from the electronic health record (EHR) (Epic). Data collected included date of admission and discharge, patient demographics, home medications, common chronic medical conditions, inpatient medications received for the treatment of COVID-19, oxygen therapy, and status at the time of discharge from the hospital. Data were available for all patients during the study period. Patients who were still admitted at the end of the study period were not included in the data analysis.

Race and ethnicity were available by self-reported status in the EHR. While patients tend to live in suburban communities, while black patients tend to live in urban and poorer communities. Home medications of interest were assessed based on medication reconciliation by the attending physician at the time of admission. Inpatient medications of interest were obtained from the medication administration record. Chronic medical conditions assessed include diabetes mellitus, hypertension, heart failure, coronary artery disease, chronic kidney disease, obesity (body mass index ≥30), asthma, and chronic obstructive pulmonary disease. Documentation of these conditions in the medical history, problem list before admission, problem list during the admission or discharge diagnoses in the EHR was used to evaluate the presence of these conditions. Patients were grouped as living or deceased based on status at the time of discharge from the hospital.

To evaluate the change in risk of mortality during the study, three periods were created: pre-peak, peak, and post-peak hospital COVID-19 volume. These periods were from 13 March 2020 to 30 March 2020, from 31 March 2020 to 13 April 2020, and from 14 April 2020 to 29 April 2020. Peak was defined as the 2 weeks when the maximum number of patients were admitted to the hospital system with a diagnosis of COVID-19.

Results

A difference in the use of some treatment medications was noted in the pre-peak, peak, and post-peak periods. Specifically, hydroxychloroquine use decreased in the post-peak period but was still used in over 60% of patients. Similarly, azithromycin use decreased in the post-peak period to less than 35% compared with over 83% in the pre-peak and peak periods. A logistic regression model was used to estimate the OR of death when controlling for age, gender, race, current smoking, and chronic medical conditions. In this model, male patients had an increased odds of dying compared with female patients. The odds of dying were 1.04 for every increase in the year of age. There was no difference in mortality based on race. The presence of diabetes mellitus, heart failure, obesity, and chronic kidney disease resulted in increased odds of death, with chronic kidney disease having the highest effect. Hypertension, coronary artery disease, asthma, chronic obstructive pulmonary disease, and current smoking status were not associated with increased odds of dying.







Discussion

Changes instituted including prone positioning, delayed mechanical ventilation, and broader use of anticoagulation. Blacks represented over half of the admitted patients with a COVID-19 diagnosis, although they only represent 17.4% of the population served by our health system. This is consistent with the Centers for Disease Control and Prevention (CDC) reports showing over-representation of blacks in hospitalized patients with COVID-19. Blacks in our study population had a lower mortality rate than whites (13.5% vs 20%), although this difference was not statistically significant when controlling for other factors. This is not consistent with other reports showing higher COVID-19 mortality in non-hospitalized and hospitalized blacks in the USA. In Michigan, 41.3% of COVID-19-related deaths are blacks, although they only represent 13.8% of the state population. Another study of hospitalized patients with COVID-19 in the state of Louisiana similarly reported lower in-hospital mortality in blacks compared with whites (21.6% vs 30.1%). In our study hospitalized blacks were younger on average than whites, with a mean age of 61.8 vs 70.5 years. Further evaluation of the data showed 26.7% of blacks in the study were 50 years of age or younger compared with 12.5% of whites, while only 11.6% of blacks were over the age of 80 years compared with 30.4% of whites. This difference in age distribution is significant; the model did control for age, so this age difference cannot entirely explain the lower rate of mortality in blacks. Comorbid conditions were common in our patient population. Specifically, rates of hypertension, diabetes, and chronic kidney disease were much higher than previously reported by the CDC and similar studies in the USA. This could be explained by many factors including the possibility that our patient population has more chronic diseases compared with other areas in the USA. Comorbid conditions that were associated with an increased risk of death were chronic kidney disease, heart failure, diabetes, and obesity, which is similar to other studies. Interestingly, hypertension was not associated with worsening in-hospital survival as reported by other studies. Concerns exist that ACEi and ARBs could increase the risk of death in patients with COVID-19.16 Although our study was not designed to answer this question, we found that the use of these medications was not associated with an increased OR of death. This was consistent with other retrospective studies.


Conclusion

Changes instituted including prone positioning, delayed mechanical ventilation, and broader use of anticoagulation. Blacks represented over half of the admitted patients with a COVID-19 diagnosis, although they only represent 17.4% of the population served by our health system. This is consistent with the Centers for Disease Control and Prevention (CDC) reports showing over-representation of blacks in hospitalized patients with COVID-19. Blacks in our study population had a lower mortality rate than whites (13.5% vs 20%), although this difference was not statistically significant when controlling for other factors. This is not consistent with other reports showing higher COVID-19 mortality in non-hospitalized and hospitalized blacks in the USA. In Michigan, 41.3% of COVID-19-related deaths are blacks, although they only represent 13.8% of the state population. Another study of hospitalized patients with COVID-19 in the state of Louisiana similarly reported lower in-hospital mortality in blacks compared with whites (21.6% vs 30.1%). In our study hospitalized blacks were younger on average than whites, with a mean age of 61.8 vs 70.5 years. Further evaluation of the data showed 26.7% of blacks in the study were 50 years of age or younger compared with 12.5% of whites, while only 11.6% of blacks were over the age of 80 years compared with 30.4% of whites. This difference in age distribution is significant; the model did control for age, so this age difference cannot entirely explain the lower rate of mortality in blacks. Comorbid conditions were common in our patient population. Specifically, rates of hypertension, diabetes, and chronic kidney disease were much higher than previously reported by the CDC and similar studies in the USA. This could be explained by many factors including the possibility that our patient population has more chronic diseases compared with other areas in the USA. Comorbid conditions that were associated with an increased risk of death were chronic kidney disease, heart failure, diabetes, and obesity, which is similar to other studies. Interestingly, hypertension was not associated with worsening in-hospital survival as reported by other studies. Concerns exist that ACEi and ARBs could increase the risk of death in patients with COVID-19.16 Although our study was not designed to answer this question, we found that the use of these medications was not associated with an increased OR of death. This was consistent with other retrospective studies. Ivermectin 3mg | Ivermectin Online Prescription | Buy Ivermectin Online (@buyivermectin) | order/ Buy Ivermectin Online Nz | No Prescription ivermectin | Ivermectol 12mg Tablet 2'S - Buy Medicines online | What's New | COVID-19 Treatment Guidelines| Ivermectin 12 Tablet 2's Price, Uses, Side Effects, Composition | UK Pharmacy: Buy Stromectol (Ivermectin) Online | buy ivermectin scabies online | Ivermectin (Stromectol) Tablets - United



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