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Risk Factors Associated With In-Hospital Mortality in a US National Sample of Patients With COVID-19

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To identify the key insights or developments described in this article
Key Points

Question  What are the epidemiologic characteristics of patients with coronavirus disease 2019 (COVID-19) treated in US hospitals, and what risk factors are associated with mortality?

Findings  In this cohort study of 64 781 patients with COVID-19 treated in 592 US hospitals during April and May 2020, the in-hospital mortality rate was 20.3% among inpatients, and severe complications were common. Receipt of statin, angiotensin-converting enzyme inhibitors, and calcium channel blockers were associated with decreased odds of mortality, but the combination use of hydroxychloroquine and azithromycin was associated with increased odds of mortality.

Meaning  In this study, COVID-19 was associated with severe complications and deaths among patients hospitalized in the United States; certain medications may be associated with decreased odds of mortality.


Importance  Coronavirus disease 2019 (COVID-19) has infected more than 8.1 million US residents and killed more than 221 000. There is a dearth of research on epidemiology and clinical outcomes in US patients with COVID-19.

Objectives  To characterize patients with COVID-19 treated in US hospitals and to examine risk factors associated with in-hospital mortality.

Design, Setting, and Participants  This cohort study was conducted using Premier Healthcare Database, a large geographically diverse all-payer hospital administrative database including 592 acute care hospitals in the United States. Inpatient and hospital-based outpatient visits with a principal or secondary discharge diagnosis of COVID-19 (International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code, U07.1) between April 1 and May 31, 2020, were included.

Exposures  Characteristics of patients were reported by inpatient/outpatient and survival status. Risk factors associated with death examined included patient characteristics, acute complications, comorbidities, and medications.

Main Outcomes and Measures  In-hospital mortality, intensive care unit (ICU) admission, use of invasive mechanical ventilation, total hospital length of stay (LOS), ICU LOS, acute complications, and treatment patterns.

Results  Overall, 64 781 patients with COVID-19 (29 479 [45.5%] outpatients; 35 302 [54.5%] inpatients) were analyzed. The median (interquartile range [IQR]) age was 46 (33-59) years for outpatients and 65 (52-77) years for inpatients; 31 968 (49.3%) were men, 25 841 (39.9%) were White US residents, and 14 340 (22.1%) were Black US residents. In-hospital mortality was 20.3% among inpatients (7164 patients). A total of 5625 inpatients (15.9%) received invasive mechanical ventilation, and 6849 (19.4%) were admitted to the ICU. Median (IQR) inpatient LOS was 6 (3-10) days. Median (IQR) ICU LOS was 5 (2-10) days. Common acute complications among inpatients included acute respiratory failure (19 706 [55.8%]), acute kidney failure (11 971 [33.9%]), and sepsis (11 910 [33.7%]). Older age was the risk factor most strongly associated with death (eg, age ≥80 years vs 18-34 years: odds ratio [OR], 16.20; 95% CI, 11.58-22.67; P < .001). Receipt of statins (OR, 0.60; 95% CI, 0.56-0.65; P < .001), angiotensin-converting enzyme inhibitors (OR, 0.53; 95% CI, 0.46-0.60; P < .001), and calcium channel blockers (OR, 0.73; 95% CI, 0.68-0.79; P < .001) was associated with decreased odds of death. Compared with patients with no hydroxychloroquine or azithromycin, patients with both azithromycin and hydroxychloroquine had increased odds of death (OR, 1.21; 95% CI, 1.11-1.31; P < .001).

Conclusions and Relevance  In this cohort study of patients with COVID-19 infection in US acute care hospitals, COVID-19 was associated with high ICU admission and in-hospital mortality rates. Use of statins, angiotensin-converting enzyme inhibitors, and calcium channel blockers were associated with decreased odds of death. Understanding the potential benefits of unproven treatments will require future randomized trials.

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Article Information

Accepted for Publication: October 18, 2020.

Published: December 10, 2020. doi:10.1001/jamanetworkopen.2020.29058

Correction: This article was corrected on January 14, 2021, to fix an error in the References section.

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2020 Rosenthal N et al. JAMA Network Open.

Corresponding Author: Ning Rosenthal, MD, PhD, MPH, Premier Applied Sciences, Premier Inc, 13034 Ballantyne Corporate Pl, Charlotte, NC 28277 (ning_rosenthal@premierinc.com).

Author Contributions: Dr Rosenthal and Mr Gundrum had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Rosenthal, Cao, Gundrum.

Drafting of the manuscript: Rosenthal, Cao.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rosenthal, Cao, Gundrum.

Administrative, technical, or material support: Rosenthal, Sianis, Safo.

Supervision: Rosenthal, Safo.

Conflict of Interest Disclosures: All authors worked on the study as full-time employees of Premier Inc. No other disclosures were reported.

Funding/Support: This study was funded by Premier Inc.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors would like to thank Bernadette Johnson Flavors, MBA, John House, MS, Teresa Davis, BS, Umang Patel, MS, and the entire PHD development team for making the data available on time for the analysis. The authors would also like to thank Denise Juliano, MS, Myla Maloney, MBA, BCMAS, Carol Cohen, BA, and the Premier Applied Sciences COVID-19 Task Force for their support with the analysis. All of the above individuals are employees of Premier Inc. No payment in addition to their regular salary was provided for their support. Dr Rosenthal has obtained written permission to include the names of individuals in this article.

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