Buntin MB, Ayanian JZ. COVID-19 Comes to the United States. JAMA Health Forum. Published online April 22, 2020. doi:10.1001/jamahealthforum.2020.0526
JAMA published today the largest case series to date, to our knowledge, of patients with coronavirus disease 2019 (COVID-19) (N = 5700) in the US, and the findings are sobering.1 The study reports clinical and demographic characteristics of a cohort of patients hospitalized with laboratory-confirmed COVID-19 between March 1 and April 4, 2020, in one of 12 urban and suburban hospitals in the metropolitan New York City region. The authors draw on detailed clinical data from electronic health records, including vital signs, laboratory tests, medications, and comorbid conditions, in a racially and ethnically diverse cohort (23% African American; 23% Hispanic; 19% with a preferred language other than English). Given all these strengths, and that New York has experienced the largest COVID-19 outbreak in the US, this study is a valuable contribution to the growing medical literature on COVID-19.
This study reports definitive short-term outcome data (deceased, discharged alive, discharged to a rehabilitation or skilled nursing facility, or readmitted) for about half of the admitted cohort (n = 2634) that experienced one of these end points by the close of the 5-week study period. However, it does not report outcomes for the other patients (n = 3066) who were still hospitalized at that point. Thus, the in-hospital mortality rate of 21% in nearly half of the cohort could be either too high—because sicker patients may die more quickly—or too low, given that a larger fraction of those with longer hospitalizations may subsequently die. Another limitation was that analyses of outcomes were not fully adjusted, and age- and sex-stratified outcomes are not sufficient to assess predictors of survival and mortality more completely. In addition, outcomes stratified by race/ethnicity, socioeconomic factors, or additional clinical factors were not reported.
So, what should health system leaders and policy makers take away from this report? First, it represents a case study of a large regional health system that managed a COVID-19 surge and was able to quickly draw on its own data systems to help track and report on a clinical crisis. Second, the rates of use of intensive care (14.2%), mechanical ventilation (12.2%), and kidney replacement therapy (3.2%) among those hospitalized can guide other US regions in planning for critical care needs. Third, short-term outcome data on the full cohort will be required before conclusions can be drawn about the effectiveness of such treatments. In particular, the alarmingly high mortality rate (88.1%) reported for those who received mechanical ventilation will need to be tempered by the outcomes of those on ventilators still hospitalized when the study ended in early April. Finally, longer-term outcomes, including functional status, recovery time, and the odds of relapse among the full cohort, will be needed to understand the total burden of COVID-19 among hospitalized patients.
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John Z. Ayanian, MD, MPP Dr John Ayanian is the inaugural Director of the Institute for Healthcare Policy and Innovation at the University of Michigan, the Alice Hamilton Distinguished University Professor of Medicine and Healthcare Policy, Professor of Health Management...
Melinda B. Buntin, PhD Dr Buntin is Professor and Chair of the Department of Health Policy, and the Mike Curb Chair for Health Policy at Vanderbilt School of Medicine. She was previously Deputy Assistant Director for Health at the US Congressional Budget Office where...