Mortality rates from COVID-19 have declined, but hospitals vary

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Mortality rates in patients with COVID-19 dropped significantly during the first 6 months of the pandemic, but outcomes depend on the hospital where patients receive care, new data show.

Dr. David Asch

“[T]its characteristic that is most associated with poor or worsening hospital outcomes is a high or increased community case rate, ”write David A. Asch, MD, MBA, executive director of the Center for Health Care Innovation at the University of Pennsylvania in Philadelphia, and colleagues .

The relationship between COVID-19 mortality rates and local prevalence suggests that “hospitals go up when cases are burdened and comply with imperatives to straighten the curve,” the authors continue. “As COVID-19 case rates increase across the country, hospital mortality outcomes may worsen.”

The researchers published their research online on December 22 at JAMA Internal Medicine.

Rapid and significant improvement in survival “is a partial recognition of a new science – for example, a science that has discovered the benefits of dexamethasone,” Asch said Medscape Medical News. “But it’s also an honor to doctors and nurses in hospitals who have gained experience. It’s a cliché to talk about them as heroes, but that’s what they are. Science and heroic experience continue, so I’m optimistic we’ll see even more improvement over time. “

However, the data also indicate that “with a lot of disease in the community, hospitals may find it harder to keep patients alive,” Asch said. “And of course the reason this is bad news is that community-level case rates are rising all the time, and in some cases at a rapid pace. With this increase, we may be regaining some of our past survival gains – just as the vaccine is starting to be distributed.”

Examination of mortality trends

The researchers analyzed data on the administrative requirements of large national health insurance. They included data from 38,517 adults admitted to COVID-19 in 955 U.S. hospitals between January 1 and June 30 this year. Investigators estimated a hospital-standardized 30-day in-hospital mortality rate or hospitalization, tailored to patient-level characteristics.

A total of 3179 patients (8.25%) died and 1433 patients (3.7%) were referred to hospice. Risk-normalized mortality rates or hospice recommendations for individual hospitals ranged from 5.7% to 24.7%. The average rate was 9.1% in the quintile with the best results, compared to 15.7% in the quintile with the lowest results.

In a subset of 398 hospitals that had at least 10 patients admitted to COVID-19 during the early (January 1 to April 30) and later periods (between May 1 and June 30), rates improved in all hospitals except in one, and 94% by at least 25%. The average rate of risk-standardized events fell from 16.6% to 9.3%.

“That rate of relative improvement is striking and encouraging, but perhaps not surprising,” Asch and co-authors write. “Early efforts to treat patients with COVID-19 were based on experience with previously known causes of severe respiratory disease. Subsequent efforts could rely on experiences specific to SARS-CoV-2 infection.”

For example, physicians have tried different approaches to inpatient management, such as early and late-assisted ventilation, differences in oxygen flow, positioning on the back or back, and anticoagulation. “These efforts have varied in how systematically they have been evaluated, but our results suggest that valuable experience has been gained,” the authors note.

In addition, differences between hospitals may reflect differences in quality or different admission thresholds, they continue.

The study provides “reason for optimism that our health care system has improved in our ability to care for people with COVID-19,” write Leon Boudourakis, Ph.D. Med., MHS and Amit Uppal, dr. Med., In a related comment. Boudourakis and Uppal are affiliated with NYC Health + Hospitals in New York, SUNY Downstate and New York University School of Medicine, respectively.

Similar improvements in mortality rates have been reported in the United Kingdom and New York’s hospital system, the editors note. Lower mortality rates may represent clinical, health system, and epidemiological trends.

“Since the first wave of serious cases of COVID-19, doctors have learned a lot about the best ways to treat this serious infection,” they say. “Steroids can reduce mortality in patients with respiratory failure. Remdesivir may shorten hospitalizations of patients with serious illness. Anticoagulation and positioning of predispositions may help certain patients. fan. “

Overloaded hospitals

“Hospitals do not work well when they are overloaded,” which could be a reason for the correlation between community prevalence and mortality rates, Boudourakis and Uppal suggested. “Patients with precarious respiratory status require professional, meticulous therapy to avoid intubation; those who undergo intubation or have renal failure require nuanced and timely professional care with ventilatory adjustments and renal replacement therapy, which is difficult to perform optimally in hospital facilities. . “

Although the death rate has dropped to about 9% in hospitalized patients, “9% is still high,” Asch said.

“Our results show that hospitals cannot do it alone,” Asch said. “We are all needed to prevent the spread of the disease in the community. The right answer now is the right answer since the beginning of the pandemic: Keep your distance, wash your hands and wear a mask.”

Asch, Boudourakis and Uppal did not disclose the relevant financial relationships. The co-author of the study reported personal fees and grants from pharmaceutical companies outside of the submitted work.

JAMA Intern Med. Published online on December 22, 2020. Full text, editorial

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