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Editor's Comment
COVID-19

COVID-19 Comes to the United States

  • 1Deputy Editor, JAMA Health Forum
  • 2Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 3Editor, JAMA Health Forum
  • 4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor

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.

References
1.
Richardson  S, Hirsch  JS, Narasimhan  M, Crawford  JM, McGinn  T, Davidson  KW; Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area  [published online April 22, 2020].  JAMA. doi:10.1001/jama.2020.6775Google Scholar
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    1 Comment for this article
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    COVID-19 Update
    Gary Ordog, MD, DABMT, DABEM | County of Los Angeles, Department of Health Services (retired)
    The authors comment on JAMA’s recent “sobering facts” about COVID-19. The WHO just announced that "The Worst of COVID-19 is still ahead.' Yesterday, governments started to relax their isolation requirements, due to pressure from freedom groups and disastrous economic circumstances. World economies have been shattered in only one month of quarantine. The price of a barrel of top oil was 'minus 37 dollars,’ yesterday it cost producers money to dispose of it! The worst is yet to come, as, by my calculation, only about one in 4000 people has been positive for the virus. If I assume that we are missing 90% of those people infected, that still means only one in 400 people have been infected, and are either immune or deceased at present. This leaves 399 out of every 400 people on the planet still to become infected. Applying a low death rate of only 0.5%; you can see their figure of 100 million. The numbers are still the same, only the shape of the curve is now ‘flattened,’ but widened. JAMA announced yesterday that there are no effective treatments except hyperimmune globulin (convalescent), but this cannot be quickly mass produced. Vaccination, the only potential ‘cure,’ was delayed by four phases of required testing (to fully 1.5 to 2 years), but even worse, the disclosure today that the virus has mutated dozens of times as it has passed around the world, making the possibility of an effective vaccine even more remote. The desperation is evident in the announcement of inhaling, ingesting, and injecting disinfectants; trust me, I have seen cases of this and it is a horrible way to die. There are those at high risk (age and premorbid condition) who may decide to remain ‘hunkered down’ until the cure is available. But, I believe governments are already moving towards the natural process of “herd immunity” and allowing the release of restrictions on most of the population, before our society degenerates back to the stone age. Those proven immune, followed by those less vulnerable, will start society, economy and industry functioning again. Without the vaccine at this point, there is nothing to change those numbers, and it is probably going to happen. The world bounced back after 1918, with 100 million lost then. At least, let’s be transparent, so people can plan their lives accordingly. Thank you.
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