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Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1966 (Published 22 May 2020) Cite this as: BMJ 2020;369:m1966

Linked Editorial

Covid-19 related hospital admissions in the United States

  1. Christopher M Petrilli, assistant professor of medicine1 2,
  2. Simon A Jones, professor of population health and statistician3 4,
  3. Jie Yang, data scientist4,
  4. Harish Rajagopalan, assistant manager2,
  5. Luke O’Donnell, hospitalist physician1,
  6. Yelena Chernyak, medical center information technology lead developer2,
  7. Katie A Tobin, assistant director2,
  8. Robert J Cerfolio, professor of cardiothoracic surgery and chief of hospital operations2 5,
  9. Fritz Francois, professor of medicine and chief medical officer2 6,
  10. Leora I Horwitz, associate professor of population health and medicine1 3 4
  1. 1Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
  2. 2NYU Langone Health, New York, NY, USA
  3. 3Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, 227 East 30th Street #633, New York, NY 10016, USA
  4. 4Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, NY, USA
  5. 5Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, NY, USA
  6. 6Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
  1. Correspondence to: L Horwitz leora.horwitz{at}nyulangone.org (or @leorahorwitzmd on Twitter)
  • Accepted 14 May 2020

Abstract

Objective To describe outcomes of people admitted to hospital with coronavirus disease 2019 (covid-19) in the United States, and the clinical and laboratory characteristics associated with severity of illness.

Design Prospective cohort study.

Setting Single academic medical center in New York City and Long Island.

Participants 5279 patients with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection between 1 March 2020 and 8 April 2020. The final date of follow up was 5 May 2020.

Main outcome measures Outcomes were admission to hospital, critical illness (intensive care, mechanical ventilation, discharge to hospice care, or death), and discharge to hospice care or death. Predictors included patient characteristics, medical history, vital signs, and laboratory results. Multivariable logistic regression was conducted to identify risk factors for adverse outcomes, and competing risk survival analysis for mortality.

Results Of 11 544 people tested for SARS-Cov-2, 5566 (48.2%) were positive. After exclusions, 5279 were included. 2741 of these 5279 (51.9%) were admitted to hospital, of whom 1904 (69.5%) were discharged alive without hospice care and 665 (24.3%) were discharged to hospice care or died. Of 647 (23.6%) patients requiring mechanical ventilation, 391 (60.4%) died and 170 (26.2%) were extubated or discharged. The strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% confidence interval 26.1 to 56.0) for ages 75 years and older. Other risks were heart failure (4.4, 2.6 to 8.0), male sex (2.8, 2.4 to 3.2), chronic kidney disease (2.6, 1.9 to 3.6), and any increase in body mass index (BMI) (eg, for BMI >40: 2.5, 1.8 to 3.4). The strongest risks for critical illness besides age were associated with heart failure (1.9, 1.4 to 2.5), BMI >40 (1.5, 1.0 to 2.2), and male sex (1.5, 1.3 to 1.8). Admission oxygen saturation of <88% (3.7, 2.8 to 4.8), troponin level >1 (4.8, 2.1 to 10.9), C reactive protein level >200 (5.1, 2.8 to 9.2), and D-dimer level >2500 (3.9, 2.6 to 6.0) were, however, more strongly associated with critical illness than age or comorbidities. Risk of critical illness decreased significantly over the study period. Similar associations were found for mortality alone.

Conclusions Age and comorbidities were found to be strong predictors of hospital admission and to a lesser extent of critical illness and mortality in people with covid-19; however, impairment of oxygen on admission and markers of inflammation were most strongly associated with critical illness and mortality. Outcomes seem to be improving over time, potentially suggesting improvements in care.

Footnotes

  • Contributors: CMP, LO’D, KAT, RJC, FF, and LIH conceived the project. CMP, YC, HR, and LIH obtained, validated, and cleaned the data. JY and SAJ performed the statistical analyses. RJC and FF provided administrative and operational support. LIH supervised the project and drafted the manuscript. All authors discussed the results and contributed to the final manuscript. LIH acts as guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This work was funded in part by the Kenneth C Griffin Charitable Fund, which had no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the article for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the Kenneth C Griffin Charitable Fund for submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the NYU Grossman School of Medicine Institutional Review Board (No i20-00485), which granted both a waiver of informed consent and a waiver of the Health Information Portability and Privacy Act.

  • Data sharing: Identifiable patient level data from this project are not available to the public.

  • Dissemination to participants and related patient and public communities: A preprint version of the study is publicly available on medRxiv at https://doi.org/10.1101/2020.04.08.20057794. Lay summaries of the article will be posted on Twitter and will be discussed with journalists as the opportunity arises.

  • The corresponding author (LIH) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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