Temporal and geographical variation of COVID-19 in-hospital fatality rate in Brazil

  1. Tatiana Pineda Portella
  2. Sara Ribeiro Mortara
  3. Rafael Lopes
  4. Andrea Sánchez-Tapia
  5. Maria Rita Donalísio
  6. Marcia C. Castro
  7. Vito Ribeiro Venturieri
  8. Camila Genaro Estevam
  9. Ana Freitas Ribeiro
  10. Renato Mendes Coutinho
  11. Maria Amélia de Sousa Mascena Veras
  12. Paulo Inácio Prado
  13. Roberto André Kraenkel

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Abstract

Background

Previous studies have shown that COVID-19 In-Hospital Fatality Rate (IHFR) varies between regions and has been diminishing over time. It is believed that the continuous improvement in the treatment of patients, age group of hospitalized, and the availability of hospital resources might be affecting the temporal and regional variation of IHFR. In this study, we explored how the IHFR varied over time and among age groups and federative states in Brazil. In addition, we also assessed the relationship between hospital structure availability and peaks of IHFR.

Methods

A retrospective analysis of all COVID-19 hospitalizations with confirmed outcomes in 22 states between March 01 and September 22, 2020 (n=345,281) was done. We fit GLM binomial models with additive and interaction effects between age groups, epidemiological weeks, and states. We also evaluated the association between the modeled peak of IHFR in each state and the variables of hospital structure using the Spearman rank correlation test.

Results

We found that the temporal variation of the IHFR was heterogeneous among the states, and in general it followed the temporal trends in hospitalizations. In addition, the peak of IHFR was higher in states with a smaller number of doctors and intensivists, and in states in which a higher percentage of people relied on the Public Health System (SUS) for medical care.

Conclusions

Our results suggest that the pressure over the healthcare system is affecting the temporal trends of IHFR in Brazil.

Key Messages

  • Temporal variation of age adjusted In-Hospital Fatality Rate (IHFR) was markedly heterogeneous among Brazilian states from March to September of 2020.

  • In several states, the IHFR increased in association with the increase in the number of hospitalizations, which suggests that the overload of the healthcare system might be affecting the temporal trends of IHFR in Brazil.

  • The IHFR remained low in the states with higher rates of hospital resources, even with the high demand for hospitalization.

  • The number of doctors and intensivist physicians per habitant was more strongly correlated with the peak of IHFR in the Brazilian states than the number of ICU beds.

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    1. ScreenIT

      SciScore for 10.1101/2021.02.19.21251949: (What is this?)

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

      Table 1: Rigor

      Institutional Review Board Statementnot detected.
      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 code and data.

      Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
      We acknowledge some limitations in our study. First, we use routinely collected secondary data on hospitalized cases of severe acute respiratory syndrome and deaths. While these data may carry some uncertainty, particularly in periods of high hospital demand and peak incidence, they are the best available official data and they are used to guide policy and decision making. Second, state analysis does not capture idiosyncrasies observed among the municipalities within the states, so even more variability is expected at the sub-state level. The testing capacity and quality of epidemiological surveillance are heterogeneous across states, with different levels of expertise for investigating and reporting cases. Lastly, our models do not include other socioeconomic factors that could affect the IHFR, such as variations in prevalence of comorbidities and nutrition status. To the best of our knowledge, this study presents the first panel of temporal trends of in-hospital fatality rate accounting for age groups in Brazilian states, and contributes to the understanding of regional disparities revealing the mosaic of epidemics of COVID-19 in the country. Contrary to previous studies that found a reduction of the IHFR of COVID-19 over time 2,5,6, our results show great heterogeneity in the IHFR temporal trends. In several states, the IHFR increased in association with the increase in the number of hospitalizations, which suggests that, in addition to medical learning, the overload of th...

      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.

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    2. Version published to 10.1101/2021.02.19.21251949v1 on medRxiv