Determinants of hospital outcomes for COVID-19 infections in a large Pennsylvania Health System

There is growing evidence that racial and ethnic minorities bear a disproportionate burden from COVID-19. Temporal changes in the pandemic epidemiology and diversity in the clinical course require careful study to identify determinants of poor outcomes. We analyzed 6255 individuals admitted with PCR-confirmed COVID-19 to one of 5 hospitals in the University of Pennsylvania Health System between March 2020 and March 2021, using electronic health records to assess risk factors and outcomes through 8 weeks post-admission. Discharge, readmission and mortality outcomes were analyzed in a multi-state model with multivariable Cox models for each transition. Mortality varied markedly over time, with cumulative incidence (95% CI) 30 days post-admission of 19.1% (16.9, 21.3) in March-April 2020, 5.7% (4.2, 7.5) in July-October 2020 and 10.5% (9.1,12.0) in January-March 2021; 26% of deaths occurred after discharge. Average age (SD) at admission varied from 62.7 (17.6) to 54.8 (19.9) to 60.5 (18.1); mechanical ventilation use declined from 21.3% to 9-11%. Compared to Caucasian, Black race was associated with more severe disease at admission, higher rates of co-morbidities and low-income resident zip code. Between-race risk differences in mortality risk diminished in multivariable models; while admitting hospital, increasing age, admission early in the pandemic, and severe disease and low blood pressure at admission were associated with increased mortality hazard. Hispanic ethnicity was associated with fewer baseline co-morbidities and lower mortality hazard (0.57, 95% CI: 0.37, .087). Multi-state modeling allows for a unified framework to analyze multiple outcomes throughout the disease course. Morbidity and mortality for hospitalized COVID-19 patients varied over time but post-discharge mortality remained non-trivial. Black race was associated with more risk factors for morbidity and with treatment at hospitals with lower mortality. Multivariable models suggest there are not between-race differences in outcomes. Future work is needed to better understand the identified between-hospital differences in mortality.

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Contrasting Monetary and Multidimensional Poverty Measures in a Low-Income Sub-Saharan African Country

Social Indicators Research ◽

10.1007/s11205-020-02382-z ◽

2020 ◽

Vol 151 (2) ◽

pp. 547-574 ◽

Cited By ~ 1

Author(s):

Lukas Salecker ◽

Anar K. Ahmadov ◽

Leyla Karimli

Keyword(s):

Risk Factors ◽

Low Income ◽

Multidimensional Poverty ◽

Poverty Measurement ◽

Sub Saharan Africa ◽

Analytical Strategy ◽

Poverty Risk ◽

Two Measures ◽

Sub Saharan ◽

Over Time

AbstractDespite significant progress in poverty measurement, few studies have undertaken an in-depth comparison of monetary and multidimensional measures in the context of low-income countries and fewer still in Sub-Saharan Africa. Yet the differences can be particularly consequential in these settings. We address this gap by applying a distinct analytical strategy to the case of Rwanda. Using data from two waves of the Rwandan Integrated Household Living Conditions Survey, we combine comparing poverty rates cross-sectionally and over time, examining the overlaps and differences in the two measures, investigating poverty rates within population sub-groups, and estimating several statistical models to assess the differences between the two measures in identifying poverty risk factors. We find that using a monetary measure alone does not capture high incidence of multidimensional poverty in both waves, that it is possible to be multidimensional poor without being monetary poor, and that using a monetary measure alone overlooks significant change in multidimensional poverty over time. The two measures also differ in which poverty risk factors they put emphasis on. Relying only on monetary measures in low-income sub-Saharan Africa can send inaccurate signals to policymakers regarding the optimal design of social policies as well as monitoring their effectiveness.

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Risk factors for severity of COVID-19: a rapid review to inform vaccine prioritisation in Canada

BMJ Open ◽

10.1136/bmjopen-2020-044684 ◽

2021 ◽

Vol 11 (5) ◽

pp. e044684

Author(s):

Aireen Wingert ◽

Jennifer Pillay ◽

Michelle Gates ◽

Samantha Guitard ◽

Sholeh Rahman ◽

...

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Mechanical Ventilation ◽

Risk Factor ◽

Intensive Care ◽

Low Income ◽

Severe Disease ◽

Male Gender ◽

Rapid Review ◽

Class Iii

ObjectivesRapid review to determine the magnitude of association between potential risk factors and severity of COVID-19, to inform vaccine prioritisation in Canada.SettingOvid MEDLINE(R) ALL, Epistemonikos COVID-19 in L·OVE Platform, McMaster COVID-19 Evidence Alerts and websites were searched to 15 June 2020. Eligible studies were conducted in high-income countries and used multivariate analyses.ParticipantsAfter piloting, screening, data extraction and quality appraisal were performed by a single experienced reviewer. Of 3740 unique records identified, 34 were included that reported on median 596 (range 44–418 794) participants, aged 42–84 years. 19/34 (56%) were good quality.OutcomesHospitalisation, intensive care unit admission, length of stay in hospital or intensive care unit, mechanical ventilation, severe disease, mortality.ResultsAuthors synthesised findings narratively and appraised the certainty of the evidence for each risk factor–outcome association. There was low or moderate certainty evidence for a large (≥2-fold) magnitude of association between hospitalisation in people with COVID-19, and: obesity class III, heart failure, diabetes, chronic kidney disease, dementia, age >45 years, male gender, black race/ethnicity (vs non-Hispanic white), homelessness and low income. Age >60 and >70 years may be associated with large increases in mechanical ventilation and severe disease, respectively. For mortality, a large magnitude of association may exist with liver disease, Bangladeshi ethnicity (vs British white), age >45 years, age >80 years (vs 65–69 years) and male gender among 20–64 years (but not older). Associations with hospitalisation and mortality may be very large (≥5-fold) for those aged ≥60 years.ConclusionsIncreasing age (especially >60 years) may be the most important risk factor for severe outcomes. High-quality primary research accounting for multiple confounders is needed to better understand the magnitude of associations for severity of COVID-19 with several other factors.PROSPERO registration numberCRD42020198001.

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Multicenter cohort study of multisystem inflammatory syndrome in children (MIS-C)

10.1101/2021.05.14.21257058 ◽

2021 ◽

Author(s):

Joanna Merckx ◽

Suzette Cooke ◽

Tala El Tal ◽

Ronald M. Laxer ◽

Ari Bitnun ◽

...

Keyword(s):

Risk Factors ◽

Cardiac Involvement ◽

Severe Disease ◽

Descriptive Analysis ◽

Median Length ◽

Multicenter Cohort Study ◽

Icu Admission ◽

Multicenter Cohort ◽

Inflammatory Syndrome ◽

Over Time

BACKGROUND: SARS-CoV-2 infection can lead to multisystem inflammatory syndrome in children (MIS-C). We investigated risk factors for severe disease and explored changes in severity over time. METHODS: Children up to 17 years of age admitted March 1, 2020 through March 7th, 2021 to 15 hospitals in Canada, Iran and Costa Rica with confirmed or probable MIS-C were included. Descriptive analysis and comparison by diagnostic criteria, country, and admission date was performed. Adjusted absolute average risks (AR) and risk differences (RD) were estimated for characteristics associated with ICU admission or cardiac involvement. RESULTS: Of 232 cases (106 confirmed) with median age 5.8 years, 56% were male, and 22% had comorbidities. ICU admission occurred in 73 (31%) but none died. Median length of stay was 6 days (inter-quartile range 4-9). Children 6 to 12 years old had the highest AR for ICU admission (44%; 95% confidence interval [CI] 34-53). Initial ferritin greater than 500 mcg/L was associated with ICU admission. When comparing cases admitted up to October 31, 2020 to those admitted later, the AR for ICU admission increased from 25% (CI 17-33) to 37% (CI 29-46) and for cardiac involvement from 44% (CI 35-53) to 75% (CI 66-84). Risk estimates for ICU admission in the Canadian cohort demonstrated a higher risk in December 2020-March 2021 compared to March-May 2020 (RD 25%; 95%CI 7-44). INTERPRETATION: MIS-C occurred primarily in previously well children. Illness severity appeared to increase over time. Despite a high ICU admission incidence, most children were discharged within one week.

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Children with SARS-CoV-2 in the National COVID Cohort Collaborative (N3C)

10.1101/2021.07.19.21260767 ◽

2021 ◽

Author(s):

Blake Martin ◽

Peter E DeWitt ◽

Seth Russell ◽

Adit Anand ◽

Katie R Bradwell ◽

...

Keyword(s):

Risk Factors ◽

African American ◽

Vital Sign ◽

Severe Disease ◽

Vital Signs ◽

Inotropic Support ◽

Clinical Severity ◽

Black African ◽

Data Elements ◽

Over Time

Importance: SARS-CoV-2 Objective: To determine the characteristics, changes over time, outcomes, and severity risk factors of SARS-CoV-2 affected children within the National COVID Cohort Collaborative (N3C) Design: Prospective cohort study of encounters with end dates before May 27th, 2021. Setting: 45 N3C institutions Participants: Children < 19-years-old at initial SARS-CoV-2 testing Main Outcomes and Measures: Case incidence and severity over time, demographic and comorbidity severity risk factors, vital sign and laboratory trajectories, clinical outcomes, and acute COVID-19 vs MIS-C contrasts for children infected with SARS-CoV-2. Results: 728,047 children in the N3C were tested for SARS-CoV-2; of these, 91,865 (12.6%) were positive. Among the 5,213 (6%) hospitalized children, 685 (13%) met criteria for severe disease: mechanical ventilation (7%), vasopressor/inotropic support (7%), ECMO (0.6%), or death/discharge to hospice (1.1%). Male gender, African American race, older age, and several pediatric complex chronic condition (PCCC) subcategories were associated with higher clinical severity (p ≤ 0.05). Vital signs (all p ≤ 0.002) and many laboratory tests from the first day of hospitalization were predictive of peak disease severity. Children with severe (vs moderate) disease were more likely to receive antimicrobials (71% vs 32%, p < 0.001) and immunomodulatory medications (53% vs 16%, p < 0.001). Compared to those with acute COVID-19, children with MIS-C were more likely to be male, Black/African American, 1-to-12-years-old, and less likely to have asthma, diabetes, or a PCCC (p < 0.04). MIS-C cases demonstrated a more inflammatory laboratory profile and more severe clinical phenotype with higher rates of invasive ventilation (12% vs 6%) and need for vasoactive-inotropic support (31% vs 6%) compared to acute COVID-19 cases, respectively (p <0.03). Conclusions: In the largest U.S. SARS-CoV-2-positive pediatric cohort to date, we observed differences in demographics, pre-existing comorbidities, and initial vital sign and laboratory test values between severity subgroups. Taken together, these results suggest that early identification of children likely to progress to severe disease could be achieved using readily available data elements from the day of admission. Further work is needed to translate this knowledge into improved outcomes.

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Mortality and risk factors among US Black, Hispanic, and White patients with COVID-19

10.1101/2020.09.08.20190686 ◽

2020 ◽

Author(s):

Tomi Jun ◽

Sharon Nirenberg ◽

Patricia Kovatch ◽

Kuan-lin Huang

Keyword(s):

Risk Factors ◽

New York ◽

Hospital Mortality ◽

Health System ◽

Race And Ethnicity ◽

Interleukin 1 ◽

The United States ◽

Black Race ◽

Hispanic Patients ◽

White Patients

Background: Little is known about risk factors for COVID-19 outcomes, particularly across diverse racial and ethnic populations in the United States. Methods: In this prospective cohort study, we followed 3,086 COVID-19 patients hospitalized on or before April 13, 2020 within an academic health system in New York (The Mount Sinai Health System) until June 2, 2020. Multivariable logistic regression was used to evaluate demographic, clinical, and laboratory factors as independent predictors of in-hospital mortality. The analysis was stratified by self-reported race and ethnicity. Findings: A total of 3,086 COVID-19 patients were hospitalized, of whom 680 were excluded (78 due to missing race or ethnicity data, 144 were Asian, and 458 were of other unspecified race/ethnicity). Of the 2,406 patients included, 892 (37.1%) were Hispanic, 825 (34.3%) were black, and 689 (28.6%) were white. Black and Hispanic patients were younger than White patients (median age 67 and 63 vs. 73, p<0.001 for both), and they had different comorbidity profiles. Older age and baseline hypoxia were associated with increased mortality across all races. There were suggestive but non-significant interactions between Black race and diabetes (p=0.09), and obesity (p=0.10). Among inflammatory markers associated with COVID-19 mortality, there was a significant interaction between Black race and interleukin-1-beta (p=0.04), and a suggestive interactions between Hispanic ethnicity and procalcitonin (p=0.07) and interleukin-8 (p=0.09). Interpretation: In this large, racially and ethnically diverse cohort of COVID-19 patients in New York City, we identified similarities and important differences across racial and ethnic groups in risk factors for in-hospital mortality.

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A Predictive Model for Severe COVID-19 in the Medicare Population: A Tool for Prioritizing Primary and Booster COVID-19 Vaccination

Biology ◽

10.3390/biology10111185 ◽

2021 ◽

Vol 10 (11) ◽

pp. 1185

Author(s):

Bettina Experton ◽

Hassan A. Tetteh ◽

Nicole Lurie ◽

Peter Walker ◽

Adrien Elena ◽

...

Keyword(s):

Risk Factors ◽

Predictive Model ◽

Low Income ◽

Social Vulnerability ◽

Risk Model ◽

Severe Disease ◽

The Elderly ◽

Chronic Obstructive ◽

Social Vulnerability Index ◽

Medicare Population

Recommendations for prioritizing COVID-19 vaccination have focused on the elderly at higher risk for severe disease. Existing models for identifying higher-risk individuals lack the needed integration of socio-demographic and clinical risk factors. Using multivariate logistic regression and random forest modeling, we developed a predictive model of severe COVID-19 using clinical data from Medicare claims for 16 million Medicare beneficiaries and socio-economic data from the CDC Social Vulnerability Index. Predicted individual probabilities of COVID-19 hospitalization were then calculated for population risk stratification and vaccine prioritization and mapping. The leading COVID-19 hospitalization risk factors were non-white ethnicity, end-stage renal disease, advanced age, prior hospitalization, leukemia, morbid obesity, chronic kidney disease, lung cancer, chronic liver disease, pulmonary fibrosis or pulmonary hypertension, and chemotherapy. However, previously reported risk factors such as chronic obstructive pulmonary disease and diabetes conferred modest hospitalization risk. Among all social vulnerability factors, residence in a low-income zip code was the only risk factor independently predicting hospitalization. This multifactor risk model and its population risk dashboard can be used to optimize COVID-19 vaccine allocation in the higher-risk Medicare population.

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Abstract 140: Long-term disability after lacunar stroke: Secondary Prevention of Small Subcortical Stroke Study

Stroke ◽

10.1161/str.45.suppl_1.140 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mandip S Dhamoon ◽

Leslie A McClure ◽

Carole L White ◽

Oscar Benavente ◽

Mitchell S Elkind

Keyword(s):

Risk Factors ◽

Secondary Prevention ◽

Recurrent Stroke ◽

Lacunar Stroke ◽

Stroke Patients ◽

Stroke Study ◽

Multivariable Models ◽

Prior Stroke ◽

Over Time

Background: Long-term disability after lacunar stroke is under-studied. We hypothesized that vascular and demographic risk factors predict worsening disability after recovery from lacunar stroke, even in the absence of recurrent stroke. Methods: The Secondary Prevention of Small Subcortical Stroke Study is a clinical trial in lacunar stroke patients with annual assessments of disability with the Older Americans Resources and Survey Instrumental Activities of Daily Living (IADL) scale (range 0-14), measuring 7 IADLs. Generalized estimating equations were used to model the likelihood of disability (IADL score <14) over time, adjusting for demographics, medical risk factors, cognitive and mood factors, and region in univariate and multivariable models. IADL assessments after recurrent stroke were censored. We stratified by study region and age quartile (<55, 55-63, 63-72, ≥72 years), and the final model excluded non-significant terms. Results: Among 2820 participants, mean age was 63.4 years (SD 10.8), 63% were male, 51% White, 32% Hispanic, 36% had some college education, 36% had diabetes, 90% had hypertension, and 10% had prior stroke. Mean follow-up was 3.5 years. Mean IADL score at 3 months was 12.5 (SD 2.5), and 43% were disabled. In multivariable models, female sex (OR 1.5, 95% CI 1.3-1.8), diabetes (1.52, 1.30-1.75), current smoking (1.28, 1.06-1.54), non-regular alcohol use (1.6, 1.4-1.9), prior stroke (1.61, 1.28-2.00), cognitive assessment screening instrument score (0.98 per point, 0.97-0.98), and depression (1.79, 1.49-2.17) were associated with disability. The youngest age quartile had decreased odds of disability over time (OR 0.56 per year, 95% CI 0.36-0.91), whereas the oldest age quartile had increased odds (1.33, 0.83-2.22). There was heterogeneity by region (p<0.0001): Americans and Latin Americans had 2.5-fold greater odds of disability per year compared to Spaniards. Conclusion: In lacunar stroke patients, older age predicted worsening long-term disability, even without recurrent stroke. Worse long-term function was associated with vascular risk factors and prior stroke, and regional differences may have been due to geographic variations in health care delivery or scale interpretation.

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Risk factors for severe outcomes of COVID-19: a rapid review

10.1101/2020.08.27.20183434 ◽

2020 ◽

Author(s):

Aireen Wingert ◽

Jennifer Pillay ◽

Michelle Gates ◽

Samantha Guitard ◽

Sholeh Rahman ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Low Income ◽

Severe Disease ◽

The United States ◽

Male Gender ◽

Rapid Review ◽

Class Iii ◽

Refugee Status ◽

Increased Risk

Background: Identification of high-risk groups is needed to inform COVID-19 vaccine prioritization strategies in Canada. A rapid review was conducted to determine the magnitude of association between potential risk factors and risk of severe outcomes of COVID-19. Methods: Methods, inclusion criteria, and outcomes were prespecified in a protocol that is publicly available. Ovid MEDLINE(R) ALL, Epistemonikos COVID-19 in LOVE Platform, and McMaster COVID-19 Evidence Alerts, and select websites were searched to 15 June 2020. Studies needed to be conducted in Organisation for Economic Co-operation and Development countries and have used multivariate analyses to adjust for potential confounders. After piloting, screening, data extraction, and quality appraisal were all performed by a single reviewer. Authors collaborated to synthesize the findings narratively and appraise the certainty of the evidence for each risk factor-outcome association. Results: Of 3,740 unique records identified, 34 were included in the review. The studies included median 596 (range 44 to 418,794) participants with a mean age between 42 and 84 years. Half of the studies (17/34) were conducted in the United States and 19/34 (56%) were rated as good quality. There was low or moderate certainty evidence for a large (≥2-fold) association with increased risk of hospitalization in people having confirmed COVID-19, for the following risk factors: obesity class III, heart failure, diabetes, chronic kidney disease, dementia, age over 45 years (vs. younger), male gender, Black race/ethnicity (vs. non-Hispanic white), homelessness, and low income (vs. above average). Age over 60 and 70 years may be associated with large increases in the rate of mechanical ventilation and severe disease, respectively. For mortality, a large association with increased risk may exist for liver disease, Bangladeshi ethnicity (vs. British white), age over 45 years (vs. <45 years), age over 80 years (vs. 65-69 years), and male gender in those 20-64 years (but not older). Associations with hospitalization and mortality may be very large (≥5-fold increased risk) for those aged over 60 years. Conclusion: Among other factors, increasing age (especially >60 years) appears to be the most important risk factor for severe outcomes among those with COVID-19. There is a need for high quality primary research (accounting for multiple confounders) to better understand the level of risk that might be associated with immigration or refugee status, religion or belief system, social capital, substance use disorders, pregnancy, Indigenous identity, living with a disability, and differing levels of risk among children. PROSPERO registration: CRD42020198001

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