key: cord-0949953-k20mto4r
authors: Bhargava, Ashish; Sharma, Mamta; Riederer, Kathleen; Fukushima, Elisa Akagi; Szpunar, Susanna M; Saravolatz, Louis
title: Risk Factors for In-hospital Mortality from COVID-19 Infection among Black Patients – An Urban Center Experience
date: 2020-09-28
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa1468
sha: 0fbc00a9ffb94b58ec1bf1a0278683403e77d41d
doc_id: 949953
cord_uid: k20mto4r

BACKGROUND: Racial disparities are central in the national conversation about Covid-19. Black/African Americans are contracting and dying from COVID-19 disproportionately. We assessed risk factors for death from COVID-19 among black inpatients at an urban center in Detroit, MI. METHODS: This was a retrospective, single-center cohort study. We reviewed the electronic medical records of patients positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the virus that causes COVID-19) on qualitative polymerase-chain-reaction assay, who were admitted between 3/8-5/6/2020. The primary outcome was in-hospital mortality. RESULTS: The case fatality rate was 29.1% (122/419). The mean duration of symptoms prior to hospitalization was 5.3 (3.9) days. Patients who died were older (mean [SD] age, 68.7 [14.8] years vs 60.3 [16.0] years; p <0.0001), had dementia (35 [28.7%] vs 34 [11.4%]; p <0.0001), hemiplegia (14 [11.5%] vs 12 [4.0%]; p=0.004), malignancy (11 [9.0%] vs 12 [4.0%]; p=0.04), and moderate-severe liver disease (4 [3.3%] vs 1 [0.3%]; p=0.01). The incidence of AMS on presentation was higher among patients who died than those who survived, 43% vs. 20.0%, respectively (p<0.0001). From multivariable analysis, the odds of death increased with age (≥60 yrs.), admission from a nursing facility, Charlson score, altered mental status, higher C-reactive protein on admission, need for mechanical ventilation, presence of shock, and acute respiratory distress syndrome. CONCLUSIONS: These demographic, clinical and laboratory factors should help healthcare providers identify black patients at highest risk for severe COVID-19-associated outcomes. Early and aggressive interventions among this at-risk population can help mitigate adverse outcomes.

rate and 6-fold higher death rate among 131 predominantly black counties compared to 2879 predominantly white counties in the US. 4 In Michigan, 33% of COVID-19 cases and 40% of deaths have occurred among black individuals, who represent 14% of the population. 5 The Detroit area, part of Wayne county in southeast Michigan, was among the earlier metro locations to experience a sudden and rapid rise in cases. City hospitals became overwhelmed with an influx of patients from nursing facilities and the community at a time when personal protective equipment (PPE) was limited and a substantial strain on Emergency department and Intensive Care Units. This pandemic has brought health disparities into the limelight and created an opportunity to address the causes underlying these inequities. 6 The Centers for Disease Control and Preventions (CDC) aligns underlying causes of health disparities that include social determinants of health, racism and discrimination, economic and educational disadvantages, health care access and quality, and occupation. 7 Miller et al reported significantly higher rates of COVID-19 diagnosis and death in disproportionately black counties which also had a greater incidence of diabetes, heart disease deaths and cerebrovascular deaths. 8 They also reported that 91% of disproportionately black counties in their analyses also ranked highest in unemployment, uninsured, and limited health system capacity. Because many black Americans work in service jobs (e.g., grocery store clerks), transportation (e.g., bus drivers), and health care (e.g., nurses, home health-care workers), A c c e p t e d M a n u s c r i p t they are at increased risks for COVID -19 virus. 9 Only one in five black Americans have an occupation that permits working from home. 10 The Bronx, with the highest black population, lowest level of education and household median income despite the lowest proportion of older adults (aged ≥65 years) reported higher rates of hospitalization and death related to COVID-19 than the other New York boroughs. 11 Understanding the clinical risk factors and laboratory biomarkers associated with severe and fatal COVID-19 among the black population in a community setting will allow early interventions to help mitigate adverse outcomes. Our study aims to identify risk factors for death from the COVID-19 infection among hospitalized black patients at Ascension St. John Hospital in Detroit, Michigan.

We conducted a single-center, retrospective cohort study at a 776-bed tertiary care academic medical center. The study was approved by the Ascension St John Hospital Institutional Review Board. Adult inpatients with confirmed COVID-19 (nasopharyngeal swab testing positive by real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay) from

March 8 th to May 6 th , 2020 were included.

Electronic medical records (EMR) were reviewed for all the patients meeting inclusion criteria. Data were collected on demographic factors such as age, sex, and residential ninedigit zip code. Clinical information including the presence of comorbid conditions (according to the Charlson Comorbidity Index), 12 initial vital signs, admission laboratory markers and management data were collected. The outcome analyzed was the case fatality rate (CFR) among hospitalized black patients.

A c c e p t e d M a n u s c r i p t

Age was assessed as a continuous variable and then categorized both as quartiles and as < 60 years ≥ 60. Obesity and severe obesity were defined according to the CDC definitions. 13 Preexisting renal disease was defined as chronic dialysis, history of renal transplant, uremic syndrome, or a creatinine > 3mg/dL on prior admissions. Malignancy was included if active or treated in the last five years. Fever was defined as an oral temperature of 37.8°C or higher.

Acute renal injury was defined as an increase in serum creatinine by ≥0.3mg/dL (≥26.5 micromol/L) within 48 hours or an increase in serum creatinine to ≥1.5 times baseline, known or presumed to have occurred within the prior seven days. 14 COVID-19 pneumonia was defined as an acute respiratory disorder meeting at least three out of four criteria: respiratory signs/symptoms (cough/ dyspnea/ tachypnea), fever, oxygen saturation below 94%, and abnormal chest x-ray at the time of hospital admission. Uncomplicated illness, severe pneumonia, acute respiratory distress syndrome (ARDS) and shock were defined according to the World Health Organization (WHO) definitions. 15 The five-digit ZIP code was also used to collect median income from 2017 United States census data.

Statistical analysis was performed using SPSS v. 27.0 (Armonk, NY). Descriptive statistics were generated to characterize the study group. Continuous variables were described as the mean with standard deviation or median with interquartile range; categorical variables were described as frequency distributions. Univariable analysis was done using Student's t-test, the Mann-Whitney U test and chi-squared analysis. Variables that were found to be significant or near-significant (p<0.09) predictors of mortality were then entered a multivariable logistic regression model using a forward likelihood ratio algorithm. For comorbidities, we included the CWIC score instead of individual comorbidities. We separated the components of the quick sepsis related organ failure assessment (qSOFA) A c c e p t e d M a n u s c r i p t because respiratory rate and mechanical intubation were highly correlated. When two variables were measuring the same underlying factor, the variable with the highest univariable measure of association was used in the model. Results from the regression are reported as odds ratios with 95% confidence intervals. All reported p values are two-sided.

A total of 419 hospitalized black patients with confirmed SARS-CoV-2 infections were A c c e p t e d M a n u s c r i p t Patients who died were significantly more likely to have dementia, hemiplegia, moderatesevere liver disease and malignancy. The mean duration of symptoms prior to the hospitalization was shorter for patients who died compared to those survived (4.6 ± 3.8 vs 5.8 ± 4.1, respectively; p=0.002). Among patients who died, 43% had altered mental status (AMS) on presentation compared to 20.0% of those who survived (p<0.0001). Black patients who died had higher rates of severe pneumonia. Use of azithromycin, hydroxychloroquine and steroids was significantly higher among patients who died than survived. For multivariable logistic regression, variables initially entered the model included age ≥ 60 yrs., CWIC, obesity, hospital admission source, systolic blood pressure at admission, oxygen saturation on admission, maximum temperature in the first 24hours of admission, AMS, WBC counts, ANC, thrombocytopenia and lymphocytopenia on admission, creatinine on A c c e p t e d M a n u s c r i p t admission, CRP on admission, total protein on admission, albumin on admission, mechanical intubation, shock, and ARDS. After nine iterations, the model with the lowest -2 log likelihood value included nine variables that were associated with increased odds of death from the COVID-19 infection, including patient age (≥60 yrs.), admission from a nursing facility, Charlson score, AMS, lymphocyte counts and CRP on admission, need for mechanical ventilation, presence of shock, and development of ARDS (Table 2) .

In our study, the CFR among black patients was 29.1% compared to 21.6% reported from Louisiana (U.S.). 16 In comparison to that study, our cohort had older patients with mean (SD) age of 62.7 (16.1) vs 60.5 (14.8), had a higher mean Charlson Comorbidity Index score (1.6±2.1 vs 1.3±2.2) and higher proportions of Medicare and Medicaid patients (55.4% vs 43.1% and 21.5% vs 11.7%) respectively. Also, as cases increased exponentially particularly in Wayne county, available testing to confirm COVID-19 was limited with results often delayed while state health departments were serving as the only approved labs early in the pandemic. This may have led to sicker patients presenting prior to hospitalization that were not readily identified as COVID-19 positive. This likely had an impact on outcomes early in the pandemic, with black residents from the metro area most at risk due to existing racial/ethnic disparities. 17 Among demographic factors, older age and admission from nursing home were independent risk factors associated with mortality among our black cohort. In our study, mortality was associated with older age, 74.6% patients who died were ≥60 years compared to 25.4% of patients who were <60 years. These findings agree with other studies that have reported increased in COVID-19 mortality with increasing age. [18] [19] [20] Our study also showed that patients admitted from nursing homes/ other facilities were a vulnerable population for severe A c c e p t e d M a n u s c r i p t COVID-19 disease and poor outcome. In our study, 109 (26%) patients were admitted from nursing homes/ other facilities and 47 (43.1%) patients died. The early COVID-19 CFR reported from the nursing homes was as high as 33%. 21 It was suspected that 40% COVID-19 related deaths in 34/40 states have occurred in these long-term care facilities. 22 In our cohort, clinical predictors associated with higher deaths among blacks were Charlson comorbidity index, presentation with AMS, requirement for intubation, development of shock and ARDS. The effect of multiple comorbidities (≥2) had shown to be synergistic, with a mortality of 15.4% compared to 5.6% in patients with one comorbidity. 23 In our study, the mean (SD) for number of comorbidities was 3 (1.7) and was higher among black patients who died compared to those who survived. Altered mental status on hospital admission was present in 42.6% of our patients who died in comparison to 19.9% who survived. Chen et al reported "disorders of consciousness" were more frequent in patients who died vs survived from the COVID-19 infection (20% versus 1%, respectively). 24 We hypothesized that several individual and local factors may have also influenced the observed outcomes. In additions to the reduced odds of survival because of common co-morbidities, lack of adequate healthcare and insurance along with the impact of poverty or general living conditions might have led to malnourishment and delayed presentation with severe illness.

Need for mechanical ventilation (MV) was the strongest predictor for mortality in our study.

We noted that, 74 intubated patients died with a mortality rate of 60.7 % which was higher compared to 24.5%, and 35.7% reported from New York and Georgia respectively. 25, 20 Death rates in our study were comparable to 56.8% reported from the United Kingdom among those who required advanced respiratory support. 26 We also noted higher mortality among black patients who developed ARDS (78.6%) and shock requiring pressors (87.5%). This contrasts with a study of critically ill patients where mortality among patients requiring vasopressors was 71% and those who developed ARDS was 75%. 27 Our institution noted an early surge of A c c e p t e d M a n u s c r i p t COVID-19 cases like New York, when ventilator and other pulmonary interventions were evolving. Also, the cohort was predominantly older and nearly 40% of studied patients were transitioned to comfort care, which may help to explain the high mortality seen in our study.

Use of hydroxychloroquine, azithromycin, and steroids were strongly associated with MV so we were unable to analyze the attributable effects of these treatment modalities towards mortality.

Among laboratory biomarkers, elevated CRP on admission was associated with higher risk of c c e p t e d M a n u s c r i p t to contribute to worse outcomes for metro Detroit residents, comprised of a higher black population at greater risk both socially and due to coexisting health conditions.

Our study showed a mortality of 29.1% among hospitalized black patients resulting from A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t 

Data from the American Time Use Survey

Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs

A new method of classifying prognostic comorbidity in longitudinal studies: development and validation

KDIGO clinical practice guidelines for acute kidney injury

World Health Organization. Clinical Management of COVID-19

Hospitalization and Mortality among Black Patients and White Patients with Covid-19

Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) -United States

Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy

ICU and Ventilator Mortality Among Critically Ill Adults with Coronavirus Disease

Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington

The Importance of Long-term Care Populations in Models of COVID-19

Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis

Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area