Trends Over Time in the Risk of Adverse Outcomes Among Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection

  1. George N Ioannou
  2. Ann M O’Hare
  3. Kristin Berry
  4. Vincent S Fan
  5. Kristina Crothers
  6. McKenna C Eastment
  7. Emily Locke
  8. Pamela Green
  9. Javeed A Shah
  10. Jason A Dominitz

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Abstract

Background

We aimed to describe trends in adverse outcomes among patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between February and September 2020 within a national healthcare system.

Methods

We identified enrollees in the national United States Veterans Affairs healthcare system who tested positive for SARS-CoV-2 between 28 February 2020 and 30 September 2020 (n = 55 952), with follow-up extending to 19 November 2020. We determined trends over time in incidence of the following outcomes that occurred within 30 days of testing positive: hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and death.

Results

Between February and July 2020, there were marked downward trends in the 30-day incidence of hospitalization (44.2% to 15.8%), ICU admission (20.3% to 5.3%), mechanical ventilation (12.7% to 2.2%), and death (12.5% to 4.4%), which subsequently plateaued between July and September 2020. These trends persisted after adjustment for sociodemographic characteristics, comorbid conditions, documented symptoms, and laboratory tests, including among subgroups of patients hospitalized, admitted to the ICU, or treated with mechanical ventilation. From February to September, there were decreases in the use of hydroxychloroquine (56.5% to 0%), azithromycin (48.3% to 16.6%), vasopressors (20.6% to 8.7%), and dialysis (11.6% to 3.8%) and increases in the use of dexamethasone (3.4% to 53.1%), other corticosteroids (4.9% to 29.0%), and remdesivir (1.7% to 45.4%) among hospitalized patients.

Conclusions

The risk of adverse outcomes in SARS-CoV-2–positive patients decreased markedly between February and July, with subsequent stabilization from July to September. These trends were not explained by changes in measured baseline patient characteristics and may reflect changing treatment practices or viral pathogenicity.

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  1. Version published to 10.1093/cid/ciab419
  2. ScreenIT

    SciScore for 10.1101/2021.03.08.21253090: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: This study was approved by the Institutional Review Board of the Veterans Affairs Puget Sound Healthcare System, which granted a waiver of informed consent.
    Consent: This study was approved by the Institutional Review Board of the Veterans Affairs Puget Sound Healthcare System, which granted a waiver of informed consent.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: Thank you for sharing your data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    There are several limitations to our study. First, while use of a Veteran cohort provided a useful window on trends in complications of SARS-CoV-2 over time within a racially diverse national health care system, our cohort includes relatively few women which may limit the generalizability of our findings. We did not capture episodes of hospitalization, ICU admission or mechanical ventilation of VA patients in non-VA facilities (unless they were paid for by the VA), but there is no evidence that such non-VA care increased substantially over the course of our study. There may also have been a delay in capturing episodes of care occurring in the community under VA purchased care. However, this would not explain the temporal trends in adverse outcomes among hospitalized patients reported here. Finally, although we adjusted for a number of sociodemographic characteristics, comorbid conditions, symptoms and laboratory tests, some residual confounding by disease severity and other unmeasured factors likely persisted. In conclusion, we identified marked improvements in outcomes of SARS-CoV-2 infection among Veterans infected during the first wave of the US pandemic with stabilization in late summer and early fall. These trends may reflect changing treatment practices, public health measures and viral pathogenicity. Studies should continue to track trends in adverse outcomes of SARS-CoV-2 infection.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  3. Version published to 10.1101/2021.03.08.21253090v1 on medRxiv