key: cord-1037627-ykplbu7o
authors: Couderc, Anne-Laure; PharmaD, Florian Correard; Hamidou, Zeinab; Nouguerede, Emilie; Arcani, Robin; Weiland, Joris; Courcier, Anais; Caunes, Pierre; Clot-Faybesse, Priscilla; Gil, Patrick; Berard, Charlotte; Miola, Charlène; Berbis, Julie; Villani, Patrick; Daumas, Aurélie
title: Factors associated with COVID-19 hospitalizations and deaths in French nursing homes
date: 2021-06-26
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.06.023
sha: c9f82f68d63bb384f1c975f6951fa7f37004735e
doc_id: 1037627
cord_uid: ykplbu7o

Objectives To describe the clinical characteristics and management of residents in French nursing homes with suspected or confirmed coronavirus disease 2019 (COVID-19), and to determine the risk factors for COVID-19-related hospitalization and death in this population. Design A retrospective multicenter cohort study Setting and Participants Four hundred and eighty nursing home residents with suspected or confirmed COVID-19 between 1 March and 20 May 2020 were enrolled and followed until 2 June 2020 in 15 nursing homes in Marseille’s greater metropolitan area. Methods Demographic, clinical, laboratory, treatment type, and clinical outcome data were collected from patients’ medical records. Multivariable analyses were used to determine factors associated with COVID-19-related hospitalization and death. For the former, the competing risk analysis - based on Fine and Gray’s model - took death into account. Results 480 residents were included. Median age was 88 years (IQR 80-93), and 330 residents were women. A total of 371 residents were symptomatic (77.3%), the most common symptoms being asthenia (47.9%), fever or hypothermia (48.1%), and dyspnea (35.6%). One hundred and twenty-three patients (25.6%) were hospitalized and 96 (20%) died. Male gender (sHR 1.63, 95% CI 1.12-2.35), diabetes (sHR 1.69, 95% CI 1.15-2.50), an altered level of consciousness (sHR 2.36, 95% CI 1.40-3.98), and dyspnea (sHR 1.69, 95% CI 1.09-2.62) were all associated with a greater risk of COVID-19-related hospitalization. Male gender (OR 6.63, 95% CI 1.04-42.39), thermal dysregulation (OR 2.64, 95% CI 1.60-4.38), falls (2.21 95% CI 1.02-4.75), and being aged >85 years old (OR 2.36 95% CI 1.32-4.24) were all associated with increased COVID-19-related mortality risk, whereas polymedication (OR 0.46, 95% CI 0.27-0.77) and preventive anticoagulation (OR 0.46, 95% CI 0.27-0.79) were protective prognostic factors. Conclusions and Implications Male gender, being aged >85 years old, diabetes, dyspnea, thermal dysregulation, an altered level of consciousness, and falls, must all be considered when identifying and protecting nursing home residents who are at greatest risk of COVID-19-related hospitalization and death.

Male gender, being aged >85 years old, diabetes, dyspnea, 25 thermal dysregulation, an altered level of consciousness, and falls, must all be considered 26 when identifying and protecting nursing home residents who are at greatest risk of 19-related hospitalization and death. Since December 2019, the number of older, frailer patients infected with severe acute 31 respiratory syndrome coronavirus 2 (SARS-CoV-2) has dramatically increased worldwide. 32 Infection rates are higher in the elderly than in younger populations, and health outcomes are biological results than younger adults. 8,9 39 In the context of the prevalence of COVID-19 in nursing home (NH) residents, research on 40 clinical characteristics, care management, and disease-related outcomes is still scarce. A study 41 in King county, Washington state, USA, reported that 54.5% of 101 NH residents infected 42 over a period of three weeks were hospitalized for COVID-19, and that 33.7% subsequently 43 died. 10 In a multicenter study in NH in Maryland, USA, residents with multiple symptoms had 44 the highest risk of mortality and hospitalization. Interestingly, asymptomatic COVID-19 was 45 also associated with higher mortality risk in that study (20.6%). 11 In France, between 1 March 46 and 31 May 2020, of the 28 771 people who died from COVID-19, more than a third (10 327 47 persons) were living in nursing homes. 12 International comparisons of data are difficult 48 because of intra-and inter-country differences in NH in terms of organization, COVID-19 49 testing policies, therapeutic management, and approaches to quantifying COVID-19-related 50 deaths. 13 However, the general observation in NH literature is that COVID-19 increased 51 mortality in NH residents in 2020. [13] [14] [15] Given the relatively small number of related studies to 63 We invited all 39 nursing homes located in the greater metropolitan area of Marseille to 64 participate in a 13-week retrospective observational cohort study. Of the 20 that agreed to 65 participate, 15 had at least one resident with suspected or confirmed COVID-19 at the time of 66 the study. The remaining five NH were therefore secondarily excluded. All residents with 67 suspected or confirmed COVID 19 between 1 March and 20 May 2020 were included. No 68 patient or patient legal representative opposed the use of their medical data when asked.

A suspected case was defined as a patient with acute respiratory illness who had been in 70 contact with a confirmed COVID-19 case in the 14 days prior to the onset of symptoms. A 71 confirmed case was defined as a suspected case who had tested positive for SARS-CoV-2 72 nucleic acid using a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) 73 assay (nasal swabs). From the moment a first case was diagnosed in any given NH, screening 74 was performed for all residents approximately every 15 days. We monitored clinical 75 outcomes, including COVID-19-related hospitalization and death, until 2 June 2020, which 76 was the study end date. This end date was chosen as lockdown relaxation rules were 77 introduced facilitating greater NH access to relatives of residents. 95 Trained physicians (ALC, AD) used a standardized electronic form to collect COVID-19-96 specific data from clinical charts, laboratory findings, and chest computerized tomography 97 (CT) scans, as well as data from NH records and treatments both for COVID-19 and for pre-98 existing comorbidities. They also collected the following data for each patient: demographic 99 information (age, gender, body mass index (BMI), most recent iso-resource dependence group 100 classification 16 ), comorbidities, and flu and pneumococcus vaccination status.

To define their level of dependency, elderly people in France are divided into one of six iso-102 resource groups, which reflect different stages of loss of autonomy. 16 NH residents classified 103 into iso-resource groups 1, 2 or 3 must be assisted in most or all their daily activities. We 104 J o u r n a l P r e -p r o o f defined cognitive impairment as a score of < 24 according to Examination 17 (MMSE) test, or the presence of cognitive impairment symptoms (wandering, 106 hallucinations, hostility/aggressiveness or history of cognitive disorder). Undernutrition and 107 obesity were defined as a BMI of < 21 and ≥ 30, respectively.

The date of disease onset was defined as the day when COVID-19 symptoms were first 109 noticed or, for asymptomatic patients, the day a patient had a positive RT-PCR test. The coma score < 14)). Data on routine blood tests (blood count, renal and liver function, C-117 reactive protein, creatine phosphokinase and D-dimers) and on chest CT scan results were 118 also collected. For all included patients, data on medications for pre-existing chronic 119 pathologies, polymedication (≥ 5 usual drugs per day), and management of COVID-19 were 120 also recorded. Some patients were 'home hospitalized', that is to say they were provided some 121 elements of hospital-type care for COVID-19 in their NH by an authorized external (i.e., not (Table 1) 159 Between 1 March and 20 May 2020, of the 1392 residents in the 15 participating nursing 160 homes in the greater metropolitan area of Marseille, a total of 480 (34.5%) had suspected or 161 confirmed COVID-19 and were included in the present study. Table 1 shows the biological characteristics of 339 patients with many missing laboratory 179 data. One hundred and forty-one patients (29.4%) did not have a blood test at diagnosis of 180 infection.

Lymphopenia, neutropenia and thrombocytopenia occurred in 109 (32.2%), 23 (6.8%) and 40 182 (11.8%) patients, respectively. The median C-reactive protein was 26 mg/L (IQR 7-67).

Of the 461 patients (96.0%) who had an RT-PCR test, 446 (92.9%) tested positive for 184 COVID-19. Only 42 patients had chest CT scans during hospitalization. All the scans showed 185 anomalies supporting the diagnosis of COVID-19.

Treatments and clinical outcomes 188 The median number of medications for pre-existing chronic illnesses was 7 (IQR 4-9.2).

Polymedication was present for 348 patients (72.5%). an increased risk of hospitalization ( Figure 1 ).

Twenty-two factors were associated with increased risk of mortality in univariate analysis 218 ( To our knowledge, our cohort is the oldest (in terms of patients' age) described in the 246 literature. 7, 8, 11, 21, 22 Unsurprisingly, all studies have shown that older patients have a poorer 247 COVID-19 prognosis. 1, 8, 23, [24] [25] [26] [27] Furthermore, the present study is one of the first to investigate 248 prognostic factors associated with the risk of hospitalization and death in NH residents.

Unlike other French and international studies 10,14 , we did not consider staff members' or 250 visitors' infectious status.

With regard to the factors listed above which were associated with hospitalization and death, 252 different studies on COVID-19 have found that men are significantly more likely to get the 253 disease than women 9,28 , and that male gender is significantly associated with COVID-19- 513  514  515  516  517  518  519  520  521  522  523  524  525  526  527  528  529  530  531  532  533  534  535  536  537  538  539  540  541  542  543  544 545 546 

High CPK level