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What factors are associated with observed trends in the in-hospital mortality rates in the United States during the first 9 months of the COVID-19 pandemic?
In this cohort study of 20 736 patients, in-hospital mortality rates decreased in the US between March and November 2020, even after accounting for the changing mix in patient age, sex, comorbidities, and disease severity at the time of admission. Hospital and intensive care unit length of stay and use of mechanical ventilation decreased over time, whereas the use of glucocorticoids and remdesivir increased.
Changes in age, sex, comorbidities, and disease severity among patients with COVID-19 do not fully explain the decrease in the in-hospital mortality rates observed during the first 9 months of the COVID-19 pandemic.
In-hospital mortality rates from COVID-19 are high but appear to be decreasing for selected locations in the United States. It is not known whether this is because of changes in the characteristics of patients being admitted.
To describe changing in-hospital mortality rates over time after accounting for individual patient characteristics.
Design, Setting, and Participants
This was a retrospective cohort study of 20 736 adults with a diagnosis of COVID-19 who were included in the US American Heart Association COVID-19 Cardiovascular Disease Registry and admitted to 107 acute care hospitals in 31 states from March through November 2020. A multiple mixed-effects logistic regression was then used to estimate the odds of in-hospital death adjusted for patient age, sex, body mass index, and medical history as well as vital signs, use of supplemental oxygen, presence of pulmonary infiltrates at admission, and hospital site.
Main Outcomes and Measures
In-hospital death adjusted for exposures for 4 periods in 2020.
The registry included 20 736 patients hospitalized with COVID-19 from March through November 2020 (9524 women [45.9%]; mean [SD] age, 61.2 [17.9] years); 3271 patients (15.8%) died in the hospital. Mortality rates were 19.1% in March and April, 11.9% in May and June, 11.0% in July and August, and 10.8% in September through November. Compared with March and April, the adjusted odds ratios for in-hospital death were significantly lower in May and June (odds ratio, 0.66; 95% CI, 0.58-0.76; P < .001), July and August (odds ratio, 0.58; 95% CI, 0.49-0.69; P < .001), and September through November (odds ratio, 0.59; 95% CI, 0.47-0.73).
Conclusions and Relevance
In this cohort study, high rates of in-hospital COVID-19 mortality among registry patients in March and April 2020 decreased by more than one-third by June and remained near that rate through November. This difference in mortality rates between the months of March and April and later months persisted even after adjusting for age, sex, medical history, and COVID-19 disease severity and did not appear to be associated with changes in the characteristics of patients being admitted.
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Accepted for Publication: March 12, 2021.
Published: May 3, 2021. doi:10.1001/jamanetworkopen.2021.8828
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Roth GA et al. JAMA Network Open.
Corresponding Author: Gregory A. Roth, MD, MPH, Division of Cardiology, Department of Medicine, University of Washington, 3980 15th Ave NE, Seattle, WA 98195 (email@example.com).
Author Contributions: Dr Roth and Ms Emmons-Bell 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: Roth, Alger, Das, de Lemos, Gakidou, Elkind, Hay, Johnson, Morrow, Rutan, Murray.
Acquisition, analysis, or interpretation of data: Roth, Emmons-Bell, Bradley, Das, de Lemos, Gakidou, Elkind, Hall, Morrow, Rodriguez, Rutan, Shakil, Sorensen, Stevens, Wang, Walchok, Williams.
Drafting of the manuscript: Roth, Hay.
Critical revision of the manuscript for important intellectual content: Emmons-Bell, Alger, Bradley, Das, de Lemos, Gakidou, Elkind, Hay, Hall, Johnson, Morrow, Rodriguez, Rutan, Shakil, Sorensen, Stevens, Wang, Walchok, Williams, Murray.
Statistical analysis: Roth, Emmons-Bell, Gakidou, Hay, Stevens.
Obtained funding: de Lemos.
Administrative, technical, or material support: de Lemos, Hay, Hall, Rodriguez, Rutan, Stevens, Walchok, Williams.
Supervision: Roth, Gakidou, Hay, Hall, Johnson, Murray.
Conflict of Interest Disclosures: Dr Alger reported being employed by the American Heart Association (AHA) during the conduct of the study. Dr Elkind reported receiving royalties from UpToDate outside the submitted work; and serving as an unpaid officer of the AHA. Dr Hall reported being an employee of the AHA. Dr Morrow reported receiving personal fees from Bayer Pharma, Merck & Co, Novartis, and Roche Diagnostics outside the submitted work; and serving as a member of the TIMI Study group, which has received institutional research grant support through Brigham and Women’s Hospital from Abbott Laboratories, Amgen, Anthos Therapeutics, Arca Biopharma, AstraZeneca, Bayer HealthCare Pharmaceuticals, BRAHMS, Daiichi-Sankyo, Eisai, GlaxoSmithKline, Intarcia, Janssen, Merck & Co, Novartis, Pfizer, Poxel, Quark Pharmaceuticals, Regeneron, Roche, Siemens, The Medicines Company, and Zora Biosciences. Dr Rodriguez reported receiving grants from the AHA/Robert Wood Johnson Harold Amos Medical Faculty Development Program and the National Heart, Lung, and Blood Institute during the conduct of the study; and receiving personal fees from HealthPals, Janssen, Novartis, and Novo Nordisk outside the submitted work. Ms Rutan reported being an employees of the AHA. Dr Wang reported receiving research grants to the Duke Clinical Research Institute from Abbott, AstraZeneca, Boston Scientific, Bristol Myers Squibb, Cryolife, Chiesi, Merck & Co, Portola, and Regeneron; and receiving personal fees from AstraZeneca, Bristol Myers Squibb, Cryolife, and Novartis outside the submitted work. Dr Williams reported being an employee of the AHA during the conduct of the study. No other disclosures were reported.
Funding/Support: The American Heart Association (AHA) suite of Registries is funded by multiple industry sponsors; the AHA COVID-19 CVD Registry is partially supported by The Gordon and Betty Moore Foundation. Dr Roth, Ms Emmons-Bell, Dr Murray, Dr Gakidou, Mr Sorensen, and Dr Hay received support from the Bill and Melinda Gates Foundation. Dr Roth was supported by grant 5R01HL136868-03 from the National Heart, Lung, and Blood Institute (NHLBI) and a grant from the Bill and Melinda Gates Foundation. Dr Roth and Ms Emmons-Bell received support from the Cardiovascular Medical Research and Education Fund. Dr Shakil received support from grant 5T32HL007828-22 from the NHLBI. Dr Rodriguez was funded by career development award K01HL144607 from the NHLBI and supported by the AHA/Robert Wood Johnson Harold Amos Medical Faculty Development Program.
Role of the Funder/Sponsor: The funders 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.
Disclaimer: Dr Bradley is an associate editor of JAMA Network Open, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Additional Contributions: Kate LeGrand, MPH, Catherine Bisignano, MPH, Darrah McCracken, PhD, and Laurie Marczak, PhD, all at the University of Washington, Seattle, provided logistical support.
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