Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study
Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study
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DOI：
10.1136/bmj.m1966
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发表时间：
2020-05-22
影响因子：
105.7
通讯作者：
Horwitz, Leora I.
中科院分区：
文献类型：
--
作者：
Petrilli, Christopher M.;Jones, Simon A.;Horwitz, Leora I.
描述2019年因冠状病毒病入院的人的结果（新冠肺炎）在美国，研究对象：5279例实验室确诊的SARS冠状病毒2型（SARS冠状病毒2型）患者（SARS-Cov-2）感染。最终随访日期为2020年5月5日。主要结局指标结局为入院、危重病（重症监护、机械通气、出院至临终关怀或死亡）和出院至临终关怀或死亡。预测因素包括患者特征、病史、生命体征和实验室检查结果。采用多变量logistic回归分析确定不良结局的危险因素，并对死亡率进行竞争风险生存分析。在11544名接受SARS-Cov-2检测的人中，5566人（48.2%）为阳性。排除后，纳入5279人。在这5279例患者中，2741例（51.9%）住院，其中1904例（69.5%）在未接受临终关怀的情况下活着出院，665例（24.3%）出院接受临终关怀或死亡。在647例（23.6%）需要机械通气的患者中，391例（60.4%）死亡，170例（26.2%）拔管或出院。入院的最大风险与年龄相关，所有年龄组中44岁以上的比值比>2，75岁及以上的比值比为37.9（95%置信区间为26.1至56.0）。其他风险包括心力衰竭（4.4，2.6至8.0），男性（2.8，2.4至3.2），慢性肾脏疾病（2.6，1.9至3.6）和体重指数（BMI）的任何增加（例如，BMI >40：2.5，1.8至3.4）。除年龄外，最大的危重病风险与心力衰竭（1.9，1.4 - 2.5）、BMI >40（1.5，1.0 - 2.2）和男性（1.5，1.3 - 1.8）有关。然而，入院时氧饱和度1（4.8，2.1 - 10.9）、C反应蛋白水平>200（5.1，2.8 - 9.2）和D-二聚体水平>2500（3.9，2.6 - 6.0）与危重病的相关性比年龄或合并症更强。在研究期间，危重病的风险显著降低。结论：在新冠肺炎患者中，肥胖和合并症是入院的强有力预测因素，在较小程度上是危重病和死亡率的预测因素;然而，入院时氧损伤和炎症标志物与危重病和死亡率的相关性最强。随着时间的推移，结果似乎在改善，这可能意味着护理的改善。
OBJECTIVETo describe outcomes of people admitted to hospital with coronavirus disease 2019 (covid-19) in the United States, and the clinical and laboratory characteristics associated with severity of illness.DESIGNProspective cohort study.SETTINGSingle academic medical center in New York City and Long Island.PARTICIPANTS5279 patients with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection between 1 March 2020 and 8 April 2020. The final date of follow up was 5 May 2020.MAIN OUTCOME MEASURESOutcomes were admission to hospital, critical illness (intensive care, mechanical ventilation, discharge to hospice care, or death), and discharge to hospice care or death. Predictors included patient characteristics, medical history, vital signs, and laboratory results. Multivariable logistic regression was conducted to identify risk factors for adverse outcomes, and competing risk survival analysis for mortality.RESULTSOf 11544 people tested for SARS-Cov-2, 5566 (48.2%) were positive. After exclusions, 5279 were included. 2741 of these 5279 (51.9%) were admitted to hospital, of whom 1904 (69.5%) were discharged alive without hospice care and 665 (24.3%) were discharged to hospice care or died. Of 647 (23.6%) patients requiring mechanical ventilation, 391 (60.4%) died and 170 (26.2%) were extubated or discharged. The strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% confidence interval 26.1 to 56.0) for ages 75 years and older. Other risks were heart failure (4.4, 2.6 to 8.0), male sex (2.8, 2.4 to 3.2), chronic kidney disease (2.6, 1.9 to 3.6), and any increase in body mass index (BMI) (eg, for BMI >40: 2.5, 1.8 to 3.4). The strongest risks for critical illness besides age were associated with heart failure (1.9,1.4 to 2.5), BMI >40 (1.5, 1.0 to 2.2), and male sex (1.5, 1.3 to 1.8). Admission oxygen saturation of 1 (4.8, 2.1 to 10.9), C reactive protein level >200 (5.1, 2.8 to 9.2), and D-dimer level >2500 (3.9, 2.6 to 6.0) were, however, more strongly associated with critical illness than age or comorbidities. Risk of critical illness decreased significantly over the study period. Similar associations were found for mortality alone.CONCLUSIONSAge and comorbidities were found to be strong predictors of hospital admission and to a lesser extent of critical illness and mortality in people with covid-19; however, impairment of oxygen on admission and markers of inflammation were most strongly associated with critical illness and mortality. Outcomes seem to be improving over time, potentially suggesting improvements in care.