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Piscitello GM, Parker WF. Do-Not-Resuscitate Orders by COVID-19 Status Throughout the First Year of the COVID-19 Pandemic. Chest 2024; 165:601-609. [PMID: 37778695 PMCID: PMC10925541 DOI: 10.1016/j.chest.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND At the beginning of the COVID-19 pandemic, whether performing CPR on patients with COVID-19 would be effective or increase COVID-19 transmission to health care workers was unclear. RESEARCH QUESTION Did the prevalence of do-not-resuscitate (DNR) orders by COVID-19 status change over the first year of the pandemic as risks such as COVID-19 transmission to health care workers improved? STUDY DESIGN AND METHODS This cross-sectional study assessed DNR orders for all adult patients admitted to ICUs at two academic medical centers in Chicago, IL, between April 2020 and April 2021. DNR orders by COVID-19 status were assessed using risk-adjusted mixed-effects logistic regression and propensity score matching by patient severity of illness. RESULTS The study population of 3,070 critically ill patients were 46% Black, 53% male, with median age (interquartile range [IQR]) 63 (50-73) years. Eighteen percent were COVID-19 positive and 27% had a DNR order. Black and Latinx patients had higher absolute rates of DNR orders than White patients (30% vs 29% vs 23%; P = .006). After adjustment for patient characteristics, illness severity, and hospital location, DNR orders were more likely in patients with COVID-19 in the nonpropensity score-matched (n = 3,070; aOR, 2.01; 95% CI, 1.64-2.38) and propensity score-matched (n = 1,118; aOR, 1.91; 95% CI, 1.45-2.52) cohorts. The prevalence of DNR orders remained higher for patients with COVID-19 than patients without COVID-19 during all months of the study period (difference in prevalence over time, P = .751). INTERPRETATION In this multihospital study, DNR orders remained persistently higher for patients with COVID-19 vs patients without COVID-19 with similar severity of illness during the first year of the pandemic. The specific reasons why DNR orders remained persistently elevated for patients with COVID-19 should be assessed in future studies, because these changes may continue to affect COVID-19 patient care and outcomes.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA; Palliative Research Center, University of Pittsburgh, Pittsburgh, PA.
| | - William F Parker
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
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Comer AR, Fettig L, Bartlett S, Sinha S, D'Cruz L, Odgers A, Waite C, Slaven JE, White R, Schmidt A, Petras L, Torke AM. Code status orders in hospitalized patients with COVID-19. Resusc Plus 2023; 15:100452. [PMID: 37662642 PMCID: PMC10470381 DOI: 10.1016/j.resplu.2023.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Background The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19. Methods A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020). Results Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80. Conclusions There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.
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Affiliation(s)
- Amber R. Comer
- Indiana University School of Health and Human Science, United States
- Indiana University School of Medicine, United States
- American Medical Association, United States
| | - Lyle Fettig
- Indiana University School of Medicine, United States
| | | | - Shilpee Sinha
- Indiana University School of Medicine, United States
| | - Lynn D'Cruz
- Indiana University School of Health and Human Science, United States
| | - Aubrey Odgers
- Indiana University School of Health and Human Science, United States
| | - Carly Waite
- Indiana University School of Health and Human Science, United States
| | | | - Ryan White
- Indiana University School of Medicine, United States
| | | | - Laura Petras
- Indiana University School of Medicine, United States
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Núñez I. Home or hospital? An observational study of what affects the place of death of people with COVID-19 in Mexico. Trans R Soc Trop Med Hyg 2023; 117:663-667. [PMID: 37099410 DOI: 10.1093/trstmh/trad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/20/2023] [Accepted: 04/16/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Out-of-hospital deaths increased during peak coronavirus disease 2019 (COVID-19) pandemic periods. However, aside from COVID-19 severity, which variables are related to being hospitalized have not been properly studied. We examine the association of several variables with dying at home from COVID-19 as opposed to in a hospital. METHODS We used COVID-19 open data from Mexico City from March 2020 until February 2021. A causal model was prespecified to identify variables of interest. Adjusted logistic regressions were performed to calculate ORs for associations between variables of interest and dying out of hospital due to COVID-19. RESULTS Among 61 112 people who died due to COVID-19, 8080 died out of hospital. Older age (OR 3.49, age 90 vs 60 y), male sex (OR 1.18) and higher bed occupancy (OR 2.68, 90% vs 50% occupancy) were positively associated with dying outside of hospital. CONCLUSION Older age could confer different patient wishes or less ability to look for healthcare. Higher bed occupancy may have prevented hospital admission from people who required in-hospital care.
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Affiliation(s)
- Isaac Núñez
- D ep artm ent of Medical Education, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 14080 Mexico City, Mexico
- Division of Postgraduate Studies, Faculty of Medicine, Universidad Nacional Autónoma de México, 04360 Mexico City, Mexico
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Li CM, Yang KC, Lee YH, Chen YH, Lin IW, Huang KC. One-Year Medical Utilization and Mortality in Home Health and Nursing Home Care Recipients from Northern Taiwan. J Am Med Dir Assoc 2023; 24:991-996. [PMID: 37268015 DOI: 10.1016/j.jamda.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Home health care (HHC) and nursing home care (NHC) are mainstays of long-term service in the aged population. Therefore, we aimed to investigate the factors associated with 1-year medical utilization and mortality in HHC and NHC recipients in Northern Taiwan. DESIGN This study employed a prospective cohort design. SETTING AND PARTICIPANTS We enrolled 815 HHC and NHC participants who started receiving medical care services from the National Taiwan University Hospital, Beihu Branch between January 2015 and December 2017. METHODS Multivariate Poisson regression modeling was used to quantify the relationship between care model (HHC vs NHC) and medical utilization. Cox proportional-hazards modeling was used to estimate hazard ratios and factors associated with mortality. RESULTS Compared with NHC recipients, HHC recipients had higher 1-year utilization of emergency department services [incidence rate ratio (IRR) 2.04, 95% CI 1.16-3.59] and hospital admissions (IRR 1.49, 95% CI 1.14-1.93), as well as longer total hospital length of stay (LOS) (IRR 1.61, 95% CI 1.52-1.71) and LOS per hospital admission (IRR 1.31, 95% CI 1.22-1.41). Living at home or in a nursing home did not affect the 1-year mortality. CONCLUSIONS AND IMPLICATIONS Compared with NHC recipients, HHC recipients had a higher number of emergency department services and hospital admissions, as well as longer hospital LOS. Policies should be developed to reduce emergency department and hospitalization utilization in HHC recipients.
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Affiliation(s)
- Chia-Ming Li
- Department of Family Medicine, National Taiwan University Hospital, Beihu Branch, Taipei, Taiwan; Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kuen-Cheh Yang
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Hsuan Lee
- Department of Family Medicine, National Taiwan University Hospital, Beihu Branch, Taipei, Taiwan; Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Hsin Chen
- Community and Geriatric Medicine Research Center, National Taiwan University Hospital Beihu Branch, Taipei, Taiwan
| | - I-Wen Lin
- Department of Family Medicine, National Taiwan University Hospital, Beihu Branch, Taipei, Taiwan; Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kuo-Chin Huang
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Community and Geriatric Medicine Research Center, National Taiwan University Hospital Beihu Branch, Taipei, Taiwan; Department of Family Medicine, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan.
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COVID-19 clinical outcomes by patient disability status: A retrospective cohort study. Disabil Health J 2023; 16:101441. [PMID: 36764842 PMCID: PMC9834120 DOI: 10.1016/j.dhjo.2023.101441] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/20/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND People with disabilities might experience worse clinical outcomes of SARS-CoV-2 infection, but evidence is limited. OBJECTIVE To investigate if people with disabilities requiring assistance are more likely to experience severe COVID-19 or death. METHODS Data from the Johns Hopkins COVID-19 Precision Medicine Analytics Platform Registry (JH-CROWN) included 6494 adult patients diagnosed with COVID-19 and admitted between March 4, 2020-October 29, 2021. Severe COVID-19 and death were defined using the occurrence and timing of clinical events. Assistive needs due to disabilities were reported by patients or their proxies upon admission. Multivariable-adjusted Cox proportional hazards models were used to examine the associations between disability status and severe COVID-19 or death. Primary models adjusted for demographics and secondary models additionally adjusted for clinical covariates. RESULTS In this clinical cohort (47-73 years, 49% female, 39% Black), patients with disabilities requiring assistance had 1.35 times (95% confidence interval [CI]:1.01, 1.81) the hazard of severe COVID-19 among patients <65 years, but not among those ≥65 years, equating to an additional 17.5 severe COVID-19 cases (95% CI:7.7, 28.2) per 100 patients. A lower risk of mortality was found among patients <65 years, but this finding was not robust due to the small number of deaths. CONCLUSIONS People with disabilities requiring assistance aged <65 years are more likely to develop severe COVID-19. Although our study is limited by using a medical model of disability, these analyses intend to further our understanding of COVID-19 outcomes among people with disabilities. Also, standardized disability data collection within electronic health records is needed.
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Graziani M, Barbieri G, Maraziti G, Falcone M, Fiaccadori A, Corradi F, Ghiadoni L, Satula K, Noumi G, Becattini C. The role of prone positioning in patients with SARS-CoV-2-related respiratory failure in non-intensive care unit. Ther Adv Respir Dis 2023; 17:17534666231164536. [PMID: 37128996 PMCID: PMC10140778 DOI: 10.1177/17534666231164536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Prone positioning (PP) is an established and commonly used lung recruitment method for intubated patients with severe acute respiratory distress syndrome, with potential benefits in clinical outcome. The role of PP outside the intensive care unit (ICU) setting is debated. OBJECTIVES We aimed at assessing the role of PP in death and ICU admission in non-intubated patients with acute respiratory failure related to COronaVIrus Disease-19 (COVID-19) pneumonia. DESIGN This is a retrospective analysis of a collaborative multicenter database obtained by merging local non-interventional cohorts. METHODS Consecutive adult patients with COVID-19-related respiratory failure were included in a collaborative cohort and classified based on the severity of respiratory failure according to the partial arterial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2) and on clinical severity by the quick Sequential Organ Failure Assessment (qSOFA) score. The primary study outcome was the composite of in-hospital death or ICU admission within 30 days from hospitalization. RESULTS PP was used in 114 of 536 study patients (21.8%), more commonly in patients with lower PaO2/FiO2 or receiving non-invasive ventilation and less commonly in patients with known comorbidities. A primary study outcome event occurred in 163 patients (30.4%) and in-hospital death in 129 (24.1%). PP was not associated with death or ICU admission (HR 1.17, 95% CI 0.78-1.74) and not with death (HR 1.01, 95% CI 0.61-1.67) at multivariable analysis; PP was an independent predictor of ICU admission (HR 2.64, 95% CI 1.53-4.40). The lack of association between PP and death or ICU admission was confirmed at propensity score-matching analysis. CONCLUSION PP is used in a non-negligible proportion of non-intubated patients with COVID-19-related severe respiratory failure and is not associated with death but with ICU admission. The role of PP in this setting merits further evaluation in randomized studies.
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Affiliation(s)
- Mara Graziani
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Via Corcianese 130, Perugia, Italy
| | - Greta Barbieri
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Giorgio Maraziti
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Marco Falcone
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Anna Fiaccadori
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Francesco Corradi
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
- Anaesthesia and Intensive Care Unit, Ospedali Galliera, Genova
| | - Lorenzo Ghiadoni
- Emergency Medicine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Katarzyna Satula
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Ghislaine Noumi
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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Núñez I, Soto-Mota A. Impact of healthcare strain on access to mechanical ventilation and mortality of hospitalized COVID-19 patients: a retrospective cohort study. Trans R Soc Trop Med Hyg 2022; 117:383-390. [PMID: 36563101 DOI: 10.1093/trstmh/trac123] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/08/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Healthcare saturation has been a prominent worry during the COVID-19 pandemic. Increase of hospital beds with mechanical ventilators has been central in Mexico's approach, but it is not known whether this actually improves access to care and the resulting quality of it. This study aimed to determine the impact of healthcare strain and other pre-specified variables on dying from coronavirus disease 2019 (COVID-19) without receiving invasive mechanical ventilation (IMV). METHODS A retrospective cohort study was conducted using open data from Mexico City between 8 May 2020 and 5 January 2021. We performed Cox proportional hazards models to identify the strength of the association between proposed variables and the outcomes. RESULTS Of 33 797 hospitalized patients with suspected or confirmed COVID-19, 19 820 (58.6%) did not require IMV and survived, 5414 (16.1%) required IMV and were intubated and 8563 (25.3%) required IMV but died without receiving it. A greater occupation of IMV-capable beds increased the hazard of death without receiving IMV (hazard ratio [HR] 1.56, comparing 90% with 50% occupation). Private healthcare was the most protective factor for death without IMV (HR 0.14). CONCLUSIONS Higher hospital bed saturation increased the hazard of dying without being intubated and worsened the outcomes among mechanically ventilated patients. Older age also increased the hazard of the outcomes, while private healthcare dramatically decreased them.
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Affiliation(s)
- Isaac Núñez
- Department of Medical Education, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico14080
| | - Adrian Soto-Mota
- Metabolic Diseases Research Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City, Mexico14080
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Subramaniam A, Tiruvoipati R, Pilcher D, Bailey M. Treatment limitations and clinical outcomes in critically ill frail patients with and without COVID-19 pneumonitis. J Am Geriatr Soc 2022; 71:145-156. [PMID: 36151970 PMCID: PMC9539196 DOI: 10.1111/jgs.18044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID-19 pneumonitis in those admitted to Australian and New Zealand ICUs. METHODS This registry-based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID-19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. RESULTS 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID-19. There were more male patients in COVID-19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE-III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%-CI 1.39-2.14), age (OR = 1.05; 95%-CI 1.04-1.06), and presence of chronic respiratory condition (OR = 1.58; 95%-CI 1.10-2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID-19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%-CI 0.98-1.96). CONCLUSIONS The proportion of treatment limitations was similar in patients with frailty with or without COVID-19 pneumonitis at ICU admission.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive CarePeninsula HealthFrankstonVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Ravindranath Tiruvoipati
- Department of Intensive CarePeninsula HealthFrankstonVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia,Centre for Outcome and Resource EvaluationAustralian and New Zealand Intensive Care SocietyMelbourneVictoriaAustralia,Department of Intensive CareAlfred HospitalMelbourneVictoriaAustralia
| | - Michael Bailey
- Centre for Outcome and Resource EvaluationAustralian and New Zealand Intensive Care SocietyMelbourneVictoriaAustralia
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Morishita N, Iwata K. The Vicissitude of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order During COVID-19 Pandemic in Japan – A Retrospective Cohort Study. Int J Gen Med 2022; 15:3943-3950. [PMID: 35431574 PMCID: PMC9012304 DOI: 10.2147/ijgm.s361582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/06/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
- Naomi Morishita
- Division of Nursing, Hyogo Prefectural Kakogawa Medical Center, Kakogawa, Hyogo, Japan
| | - Kentaro Iwata
- Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
- Correspondence: Kentaro Iwata, Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuoku, Kobe, Hyogo, 650-0017, Japan, Tel +81-78-382-6296, Fax +81-78-382-6298, Email
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Antoniello A, Brophy A, Opsha Y. Evaluation of Hospitalized Patient Outcomes in COVID-19 Infection for Continued versus Discontinued Use of Preadmission Antiplatelet Regimen. J Pharm Pract 2021; 36:508-513. [PMID: 34693824 DOI: 10.1177/08971900211053294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In SARS-CoV-2 (COVID-19) infection, it is unclear if continuation of preadmission antiplatelet regimens upon hospitalization will improve hypercoagulability outcomes. METHODS This retrospective cohort study analyzed adult patients hospitalized with confirmed COVID-19 infection for a 6-week period from March 13, 2020, to April 27, 2020. Preadmission antiplatelet regimen continuation for less than 75% of admission was compared to continuation for at least 75% of admission. Pregnancy, either death or withdrawal of care within 24 hours of admission, and admission beyond the studied timeframe were excluded. The primary endpoint was difference in World Health Organization COVID-19 Ordinal Scale for Clinical Improvement values (World Health Organization [WHO] scores) between maximum score during admission to that upon discharge. Secondary endpoints were mechanical ventilation requirement, mortality, radiologically confirmed venous thromboembolism, major bleeding, and length of stay. RESULTS This study included 171 patients. Patients failing to continue antiplatelet regimens for at least 75% of admission (n = 76) had significantly worse WHO score differences than those who did (n = 95) (median -1 vs 2; P < .05). Mechanical ventilation requirement (57% vs 27%; P < .05) and mortality (58% vs 29%; P < .05) also favored antiplatelet continuation. All other endpoints were not significantly different. CONCLUSION Significantly improved WHO scores, mechanical ventilation requirement, and mortality occurred in patients continuing preadmission antiplatelet regimens in COVID-19 infection. Future prospective studies of COVID-19 patients with consistently collected baseline hypercoagulability markers (platelets, D-dimer, fibrinogen, and coagulation studies) and similar severe disease risk factors are required to confirm potential benefits of antiplatelet therapy during hospitalization.
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Affiliation(s)
- Angela Antoniello
- Saint Barnabas Medical Center - Department of Pharmacy, Livingston, NJ, USA
| | - Alison Brophy
- Saint Barnabas Medical Center - Department of Pharmacy, Livingston, NJ, USA
| | - Yekaterina Opsha
- Saint Barnabas Medical Center - Department of Pharmacy, Livingston, NJ, USA.,24056Rutgers University - Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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Sinvani L, Marziliano A, Makhnevich A, Tarima S, Liu Y, Qiu M, Zhang M, Ardito S, Carney M, Diefenbach M, Davidson K, Burns E. Geriatrics-focused indicators predict mortality more than age in older adults hospitalized with COVID-19. BMC Geriatr 2021; 21:554. [PMID: 34649521 PMCID: PMC8515323 DOI: 10.1186/s12877-021-02527-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/24/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to utilize administrative data to build an explanatory model accounting for geriatrics-focused indicators to predict mortality in hospitalized older adults with COVID-19. METHODS Retrospective cohort study of adults age 65 and older (N = 4783) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Stepwise logistic regression with Akaike Information Criterion minimization was used. RESULTS The average age was 77.4 (SD = 8.4), 55.9% were male, 20.3% were African American, and 15.0% were Hispanic. In multivariable analysis, male sex (adjusted odds ration (adjOR) = 1.06, 95% CI:1.03-1.09); Asian race (adjOR = 1.08, CI:1.03-1.13); history of chronic kidney disease (adjOR = 1.05, CI:1.01-1.09) and interstitial lung disease (adjOR = 1.35, CI:1.28-1.42); low or normal body mass index (adjOR:1.03, CI:1.00-1.07); higher comorbidity index (adjOR = 1.01, CI:1.01-1.02); admission from a facility (adjOR = 1.14, CI:1.09-1.20); and mechanical ventilation (adjOR = 1.52, CI:1.43-1.62) were associated with mortality. While age was not an independent predictor of mortality, increasing age (centered at 65) interacted with hypertension (adjOR = 1.02, CI:0.98-1.07, reducing by a factor of 0.96 every 10 years); early Do-Not-Resuscitate (DNR, life-sustaining treatment preferences) (adjOR = 1.38, CI:1.22-1.57, reducing by a factor of 0.92 every 10 years); and severe illness on admission (at 65, adjOR = 1.47, CI:1.40-1.54, reducing by a factor of 0.96 every 10 years). CONCLUSION Our findings highlight that residence prior to admission, early DNR, and acute illness severity are important predictors of mortality in hospitalized older adults with COVID-19. Readily available administrative geriatrics-focused indicators that go beyond age can be utilized when considering prognosis.
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Affiliation(s)
- Liron Sinvani
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA. .,Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA. .,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA. .,Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA.
| | - Allison Marziliano
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
| | - Alex Makhnevich
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA.,Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Sergey Tarima
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yan Liu
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
| | - Michael Qiu
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
| | - Meng Zhang
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
| | - Suzanne Ardito
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA
| | - Maria Carney
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA
| | - Michael Diefenbach
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Karina Davidson
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Edith Burns
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research, Northwell Health, 600 Community Drive, Suite 403, Manhasset, NY, 11030, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.,Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA
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Sutton L, Goodacre S, Thomas B, Connelly S. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study. Resuscitation 2021; 164:130-138. [PMID: 33961960 PMCID: PMC8095017 DOI: 10.1016/j.resuscitation.2021.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/14/2021] [Accepted: 04/27/2021] [Indexed: 11/15/2022]
Abstract
AIMS We aimed to describe the characteristics and outcomes of adults admitted to hospital with suspected COVID-19 according to their DNACPR decisions, and identify factors associated with DNACPR decisions. METHODS We undertook a secondary analysis of 13,977 adults admitted to hospital with suspected COVID-19 and included in the Pandemic Respiratory Infection Emergency System Triage (PRIEST) study. We recorded presenting characteristics and outcomes (death or organ support) up to 30 days. We categorised patients as early DNACPR (before or on the day of admission) or late/no DNACPR (no DNACPR or occurring after the day of admission). We undertook descriptive analysis comparing these groups and multivariable analysis to identify independent predictors of early DNACPR. RESULTS We excluded 1249 with missing DNACPR data, and identified 3929/12748 (31%) with an early DNACPR decision. They had higher mortality (40.7% v 13.1%) and lower use of any organ support (11.6% v 15.7%), but received a range of organ support interventions, with some being used at rates comparable to those with late or no DNACPR (e.g. non-invasive ventilation 4.4% v 3.5%). On multivariable analysis, older age (p < 0.001), active malignancy (p < 0.001), chronic lung disease (p < 0.001), limited performance status (p < 0.001), and abnormal physiological variables were associated with increased recording of early DNACPR. Asian ethnicity was associated with reduced recording of early DNACPR (p = 0.001). CONCLUSIONS Early DNACPR decisions were associated with recognised predictors of adverse outcome, and were inversely associated with Asian ethnicity. Most people with an early DNACPR decision survived to 30 days and many received potentially life-saving interventions. REGISTRATION ISRCTN registry, ISRCTN28342533, http://www.isrctn.com/ISRCTN28342533.
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Affiliation(s)
- Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | - Ben Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | - Sarah Connelly
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
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Bondeelle L, Chevret S, Cassonnet S, Harel S, Denis B, de Castro N, Bergeron A. Profiles and outcomes in patients with COVID-19 admitted to wards of a French oncohematological hospital: A clustering approach. PLoS One 2021; 16:e0250569. [PMID: 34010331 PMCID: PMC8133400 DOI: 10.1371/journal.pone.0250569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/09/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Although some prognostic factors for COVID-19 were consistently identified across the studies, differences were found for other factors that could be due to the characteristics of the study populations and the variables incorporated into the statistical model. We aimed to a priori identify specific patient profiles and then assess their association with the outcomes in COVID-19 patients with respiratory symptoms admitted specifically to hospital wards. METHODS We conducted a retrospective single-center study from February 2020 to April 2020. A non-supervised cluster analysis was first used to detect patient profiles based on characteristics at admission of 220 consecutive patients admitted to our institution. Then, we assessed the prognostic value using Cox regression analyses to predict survival. RESULTS Three clusters were identified, with 47 patients in cluster 1, 87 in cluster 2, and 86 in cluster 3; the presentation of the patients differed among the clusters. Cluster 1 mostly included sexagenarian patients with active malignancies who were admitted early after the onset of COVID-19. Cluster 2 included the oldest patients, who were generally overweight and had hypertension and renal insufficiency, while cluster 3 included the youngest patients, who had gastrointestinal symptoms and delayed admission. Sixty-day survival rates were 74.3%, 50.6% and 96.5% in clusters 1, 2, and 3, respectively. This was confirmed by the multivariable Cox analyses that showed the prognostic value of these patterns. CONCLUSION The cluster approach seems appropriate and pragmatic for the early identification of patient profiles that could help physicians segregate patients according to their prognosis.
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Affiliation(s)
- Louise Bondeelle
- Université de Paris, Hôpital Saint-Louis, AP-HP, Service de Pneumologie, Paris, France
| | - Sylvie Chevret
- ECSTRRA Team, Université de Paris, Inserm, Paris, France
- Service de Biostatistique et Information Médicale, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Stéphane Cassonnet
- Service de Biostatistique et Information Médicale, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Stéphanie Harel
- Hôpital Saint-Louis, AP-HP, Service d’Immuno-hématologie, Paris, France
| | - Blandine Denis
- Hôpital Saint-Louis, AP-HP, Service de Maladies Infectieuses, Paris, France
| | - Nathalie de Castro
- Hôpital Saint-Louis, AP-HP, Service de Maladies Infectieuses, Paris, France
| | - Anne Bergeron
- Université de Paris, Hôpital Saint-Louis, AP-HP, Service de Pneumologie, Paris, France
- ECSTRRA Team, Université de Paris, Inserm, Paris, France
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