Changes in in-hospital mortality in the first wave of COVID-19: a multicentre prospective observational cohort study using the WHO Clinical Characterisation Protocol UK.
Changes in in-hospital mortality in the first wave of COVID-19: a multicentre prospective observational cohort study using the WHO Clinical Characterisation Protocol UK.
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DOI：
10.1016/s2213-2600(21)00175-2
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发表时间：
2021-07
期刊：
影响因子：
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通讯作者：
ISARIC4C Investigators
中科院分区：
文献类型：
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作者：
Docherty AB;Mulholland RH;Lone NI;Cheyne CP;De Angelis D;Diaz-Ordaz K;Donegan C;Drake TM;Dunning J;Funk S;García-Fiñana M;Girvan M;Hardwick HE;Harrison J;Ho A;Hughes DM;Keogh RH;Kirwan PD;Leeming G;Nguyen Van-Tam JS;Pius R;Russell CD;Spencer RG;Tom BD;Turtle L;Openshaw PJ;Baillie JK;Harrison EM;Semple MG;ISARIC4C Investigators
在第一波大流行期间，英国住院的 COVID-19 患者的死亡率似乎有所下降。我们的目的是量化这一变化的潜在驱动因素，并确定仍处于医院死亡高风险的患者群体。在这项多中心前瞻性观察队列研究中，国际严重急性呼吸道和新发感染联盟世界卫生组织英国临床特征协议招募了一组前瞻性队列，参与者是第一波大流行期间（2020年3月9日至8月2日）英格兰、苏格兰和威尔士247家急症医院收治的COVID-19患者。我们纳入了所有年龄在 18 岁及以上且具有 COVID-19 临床体征和症状的患者，或因假定的社区获得性感染而确诊的 COVID-19（通过 RT-PCR 检测）。我们使用自然效应模型进行了三向分解中介分析，以探索入院周与院内死亡率之间的关联，调整混杂因素（人口统计、合并症和疾病严重程度）并量化潜在中介因素（呼吸支持和类固醇治疗水平）。主要结局是每周 28 天的院内死亡率，定义为观察周内所有入院患者中入院 28 天内死亡的患者比例，并对所有患者进行结局评估。本研究已在 ISRCTN 登记处注册，ISRCTN66726260。 2020年3月9日至8月2日期间，我们招募了80 713名患者，其中63 972名患者符合条件并纳入研究。未经调整的每周住院死亡率从2020年3月9日至4月26日的32·3% (95% CI 31·8–32·7)下降至2020年6月15日至8月2日的16·4% (15·0–17·8)。在所有年龄组、所有种族、男女以及患有和不患有这种疾病的患者中都观察到死亡率下降。合并症。调整后，每 7 周的死亡风险降低了 32%（比值比 [OR] 0·68 [95% CI 0·65–0·71]）。第一波（3 月和 4 月）早期患有严重疾病和合并症的患者比例高于 6 月和 7 月，占这一减少的 10·2%。呼吸支持的使用在第一波期间发生了变化，与第一波相比，无创通气的使用逐渐增加。呼吸支持的改变和类固醇的使用占院内死亡率降低的 22·2% 或 0·95 (0·94–0·95)。在英国第一波疫情期间，COVID-19 患者的院内死亡率下降，部分原因是病例组合和疾病严重程度的变化。院内死亡率的显着降低与呼吸支持和重症监护使用的差异有关，这可能部分反映了临床知识的积累。院内死亡率的其余改善并不能用这些因素来解释，可能与社区行为、接种剂量和医院容量紧张的变化有关。国家健康研究所和医学研究委员会。
Mortality rates in hospitalised patients with COVID-19 in the UK appeared to decline during the first wave of the pandemic. We aimed to quantify potential drivers of this change and identify groups of patients who remain at high risk of dying in hospital. In this multicentre prospective observational cohort study, the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK recruited a prospective cohort of patients with COVID-19 admitted to 247 acute hospitals in England, Scotland, and Wales during the first wave of the pandemic (between March 9 and Aug 2, 2020). We included all patients aged 18 years and older with clinical signs and symptoms of COVID-19 or confirmed COVID-19 (by RT-PCR test) from assumed community-acquired infection. We did a three-way decomposition mediation analysis using natural effects models to explore associations between week of admission and in-hospital mortality, adjusting for confounders (demographics, comorbidities, and severity of illness) and quantifying potential mediators (level of respiratory support and steroid treatment). The primary outcome was weekly in-hospital mortality at 28 days, defined as the proportion of patients who had died within 28 days of admission of all patients admitted in the observed week, and it was assessed in all patients with an outcome. This study is registered with the ISRCTN Registry, ISRCTN66726260. Between March 9, and Aug 2, 2020, we recruited 80 713 patients, of whom 63 972 were eligible and included in the study. Unadjusted weekly in-hospital mortality declined from 32·3% (95% CI 31·8–32·7) in March 9 to April 26, 2020, to 16·4% (15·0–17·8) in June 15 to Aug 2, 2020. Reductions in mortality were observed in all age groups, in all ethnic groups, for both sexes, and in patients with and without comorbidities. After adjustment, there was a 32% reduction in the risk of mortality per 7-week period (odds ratio [OR] 0·68 [95% CI 0·65–0·71]). The higher proportions of patients with severe disease and comorbidities earlier in the first wave (March and April) than in June and July accounted for 10·2% of this reduction. The use of respiratory support changed during the first wave, with gradually increased use of non-invasive ventilation over the first wave. Changes in respiratory support and use of steroids accounted for 22·2%, OR 0·95 (0·94–0·95) of the reduction in in-hospital mortality. The reduction in in-hospital mortality in patients with COVID-19 during the first wave in the UK was partly accounted for by changes in the case-mix and illness severity. A significant reduction in in-hospital mortality was associated with differences in respiratory support and critical care use, which could partly reflect accrual of clinical knowledge. The remaining improvement in in-hospital mortality is not explained by these factors, and could be associated with changes in community behaviour, inoculum dose, and hospital capacity strain. National Institute for Health Research and the Medical Research Council.