High Mortality among Older Patients Hospitalized with COVID-19 during the First Pandemic Wave

44 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 3

Understanding the local epidemiology, including mortality, of COVID-19 is 45 important for guiding optimal mitigation strategies such as vaccine implementation, need for 46 study of more effective treatment, and redoubling of focused infection control measures. 47

A retrospective observational cohort study design was utilized. We included adult 48 patients diagnosed in the hospital or emergency department with COVID-19 from March 8, 2020 49 through May 17, 2020 at Grady Memorial Hospital (Atlanta, GA). Medical chart data abstraction 50 was performed to collect clinical, laboratory and outcome data. Death, defined as inpatient 51 mortality or discharge to hospice, was the primary outcome. 52

Among 360 persons with laboratory-confirmed COVID-19, 50% were ≥ 60 years, and 53 most (80%) were Black and had a BMI ≥25 kg/m2 (64%). A total of 53 patients (15%) had an 54 outcome of death with the majority (n=46, 88%) occurring in persons ≥ 60 years. Persons ≥ 60 55 years were less likely to have typical COVID-19 symptoms while more likely to have multiple 56 comorbidities, multifocal pneumonia, and to be admitted to intensive care. The death rate was 57 27% among persons ≥60 years versus 4% in those <60 years (p<.01). Furthermore, most deaths 58 (n=40, 75%) occurred among residents of long-term care facilities (LCFs). 59

We describe early COVID-19 cases among predominantly Black and older 60 patients from a single center safety net hospital. COVID-19 related mortality occurred 61 predominantly among older patients from LCFs highlighting the need for improved preparedness 62 and supporting prioritization of vaccination efforts in such settings. 63 64 65 66

67 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 4 The novel coronavirus (COVID-19) pandemic took the world by surprise in early 2020 and has 68 led to a staggering death toll during the subsequent year with no immediate end in sight. 69 Researchers quickly mobilized to combat the pandemic, turning COVID-19 into the predominant 70 and persistent focus of the scientific and medical communities.1 Unprecedented breakthroughs in 71 therapeutics and vaccines have provided hope.2, 3 However, health inequities, vaccine uptake and 72 distribution challenges, human behavior, emerging viral variants, and other challenges will likely 73 contribute to the continued circulation of SARS-CoV-2.4, 5 Massive epidemiological efforts 74 focused on COVID-19 have revealed that populations affected and clinical outcomes differ by 75 time and place stressing the importance of understanding the pandemic at a local level. 6, 7 76 77 Utilizing available estimates, the United States has had one of the highest prevalences of 78 COVID-19 cases and COVID-19 related deaths in the world. As of March 18, 2021 the U.S. 79 accounted for ~24% (~29.3 million) of all COVID-19 cases worldwide as well as ~20% 80 (~531,855) of all deaths.7, 8 While COVID-19 has affected all strata of the population, increasing 81 age and residence in a long-term care facility (LCF) were identified early on as risk factors for 82 COVID-19 acquisition and severe disease. One of the first reports from the U.S. detailed the fast 83 spread of COVID-19 among LCFs in Seattle highlighting the importance of preventive measures 84 in such settings.9 A subsequent report from 18 states found that >50% of all their COVID-19 85 related deaths occurred among persons living in LCFs and estimated that > 100,000 COVID-19 86 deaths in the U.S. have occurred among LCFs residents.10 Furthermore, while recent data has 87 implicated COVID-19 as the leading cause of death in the U.S., the highest death rates were seen 88 in persons > 65 years.11 89 90 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 5 The purpose of our study was to evaluate the clinical characteristics of patients with COVID-19 91 at an urban, safety-net hospital in the South during the first wave of the pandemic and to identify 92 patient factors associated with mortality from COVID-19. As the COVID-19 pandemic has 93 evolved to include broader segments of the population, additional data to identify those most at 94 risk of severe disease in certain settings is important to guide optimal use of limited resources 95 now and in the future. We expect our data will inform ongoing surveillance and prevention 96 efforts in the South and potentially provide valuable information to encourage high risk groups 97 including those with higher rates of vaccine hesitancy to be immunized.12 98 99

100 Study Design and Participants 101 A retrospective observational cohort study design was utilized. We included adult patients 102 diagnosed with COVID-19 in either the hospital or emergency room from March 8, 2020 103 through May 17, 2020 at Grady Memorial Hospital. Grady Memorial Hospital is an 800-bed 104 safety-net hospital in Atlanta, Georgia which diagnosed its first case of COVID-19 on March 8, 105 2020. Of note during the study period, the Grady nursing to patient ration remained between 1:1 106 to 1:3 in the intensive care unit. A positive polymerase chain reaction (PCR) assay for SARS-107 CoV-2 was required for inclusion. During our study period, nasopharyngeal swab samples were 108 collected for all persons under investigation and analyzed with the Abbott Laboratories m2000 109 RealTime (Lake Bluff, IL) system. Patients who were diagnosed in the outpatient setting without 110 an admission order were excluded. Additionally, participants with their first SARS-CoV-2 PCR 111 test performed ≥5 days after hospitalization were excluded. The study was approved by the 112 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 6 Emory University Institutional Review Board and the Grady Memorial Hospital Research 113 Oversight Committee. 114 115 Data Management 116 COVID-19 surveillance data was obtained from Grady Memorial Hospital EPIC electronic 117 medical record (EMR) system (Epic Systems Corporation, Verona, WI) as well as from the 118 microbiology laboratory. Utilizing the EPIC Clinical Workbench Reporting feature, we exported 119 a list of patients who had received a SARS-CoV-2 test. Additionally, a list of patients admitted to 120 the hospital who had a SARS-CoV-2 test was generated from the microbiology laboratory. 121 Demographic information including age, sex, and race were included in the data pull when 122 available. Data were exported from both methods on a weekly basis. An R script was created in 123 RStudio (version 1.2.5, RStudio Inc., 2020) that cross-referenced patients from the two data sets 124 using the medical record number and updated a cumulative R dataset weekly. The primary 125 variable for assessing disease prevalence was the SARS-CoV-2 test result, and the date the 126 sample was received by the laboratory was used as the time point. If a patient had multiple 127 positive SARS-CoV2 test results over the collection period, only the first result and time were 128 included in analyses. At the end of the collection period, the R data were uploaded into an 129 HIPAA compliant online Research Electronic Data Capture (REDCap) database13 hosted by 130 Emory University. Utilizing the list of patients with a positive SARS-CoV-2 test generated 131 above, an electronic medical chart data abstraction was performed for each participant and data 132 (patient demographics, medical history, symptoms, laboratory values, radiology results, 133 treatment and clinical outcomes) was entered into the REDCap database. 134 135 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 7 Data Analysis 136 Data analyses were performed using RStudio (version 3.6.3, R Core Team, 2020). Death was the 137 main outcome of interest and was defined as inpatient mortality or discharge to hospice. Older 138 patients were defined by age ≥60 years. Sequential organ failure assessment (SOFA) and quick 139 SOFA (qSOFA) scores were calculated for each patient with simplified vasopressor categories 140 using a custom R package (https://github.com/michaelwoodworth/sepsisscores).14 Bivariate 141 analysis was performed to compare characteristics (demographics, comorbidities, treatment 142 received and laboratory and radiology results) between patients by vital status and by age 143 category. 144 145

146 A total of 4049 participants had a SARS-CoV2 PCR test performed during the study period 147 including 34.6% who were ≥60 years and 70.9% who were Black or African American. A total 148 of 360 (8.9%) had a positive test. Among the 360 patients with COVID-19, 50% were ≥60 years, 149 and 80% were Black and 64% had a body mass index ≥25 kg/m2. Regarding place of residence 150 prior to admission, 106 patients (29%) resided in a LCF (Table 1). The most common 151 comorbidity was hypertension (66%) followed by diabetes mellitus (31%) (Table 1). The 152 majority of patients (67%) had an abnormal chest radiograph with bilateral opacities being the 153 most common finding (45%). Almost one quarter (24%) of patients were admitted to either 154 intermediate or intensive care and 16% of patients received mechanical ventilation during their 155 hospitalization. Only 14 patients (4%) received remdesivir as it only became available near the 156 end of the study period through participation in a clinical trial. 157 158 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 8 There were a total of 53 deaths (15%), including 31 with in-hospital death and 22 patients 159 discharged to hospice. The majority of deaths (87%) occurred among patients ≥60 years old and 160 among persons who resided in a LCF prior to admission (76%). No deaths occurred in patients 161 <40 years old. Approximately half of patients admitted to the intensive care (51%) and patients 162 receiving mechanical ventilation (54%) died. 163 164 Given the high rate of death in older persons with COVID-19, we next compared characteristics 165 by age category (≥60 vs. < 60 years). Older patients were more likely to have multiple chronic 166 comorbidities including hypertension, congestive heart failure, prior cerebrovascular accident, 167 dementia, and chronic kidney disease (Table 2). Older patients were less likely to have upper 168 respiratory viral symptoms compared to patients < 60 years (including fever, cough, chills and 169 myalgias). The only symptom more common in older patients was altered mental status (46 vs. 170 8%, p<.01). Multifocal lung lesions were more common on chest x-ray in older patients (21 vs. 171 11%, p=0.01). Older patients were also more likely to be admitted to either intermediate or 172 intensive care (35 vs. 14%, p<.01) and more likely to receive mechanical ventilation (22 vs. 173 10%, p<.01). Among patients with COVID-19, a total of 27% older persons compared to 4% 174 (p<.01) of patients < 60 years died during the study period. 175 176

177 In this study of clinical outcomes among 360 patients with COVID-19 at a large Southern safety- 178 net hospital during the first wave of the COVID-19 pandemic, we found a high overall death rate 179 of 15% with the majority of deaths (87%) occurring in persons ≥60 years. Furthermore, most 180 deaths occurred among residents of LCFs, many of whom were afflicted with multiple 181 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 9 comorbidities. Our findings highlight the vulnerability of elderly populations living in LCFs to 182 communicable disease and stress the need to implement better preventive and control measures 183 to deal with such crises now and in the future. 184 185 Our findings also highlight the disproportionate burden of COVID-19 and related death among 186 certain racial groups. We found the majority of patients who were hospitalized (80%) with and 187 died (87%) from COVID-19 were Black. Compared to all patients tested for COVID-19, we 188 found that persons ≥60 years (44 vs. 34.6%) or Black or African American (80 vs. 70.9%) were 189 more likely to be infected with COVID-19. Additionally, a prior report on patients hospitalized 190 with COVID-19 in Georgia found a similar a prevalence of Black patients (83%) which was 191 much higher than the proportion of Black persons among all hospitalized patients (47%) in the 192 same period. 15 A large cohort of patients hospitalized with COVID-19 in Louisiana echoed 193 findings in Georgia, with 77% of all hospitalized patients being Black and 71% of deaths 194 occurring among those who were Black, despite the fact that Blacks comprised only 31% of the 195 health population. 16 Social vulnerabilities and racial inequalities are likely major factors leading 196 to racial disparities in COVID-19 illness. 17 The racial health disparities exposed by the COVID-197 19 pandemic have created needed opportunity and momentum for the healthcare system to 198 address health inequities and improve the health and well-being of all persons in the US. 18 199 200 Our high deaths rates among older patients most of whom resided in LCFs was alarming and 201 raises several important points. First, older patients are at much higher risk for COVID-19 202 related mortality. This has been shown for the US where 81% of all COVID-19 related deaths 203 are among persons 65 and older and in other countries with available data that have similarly 204 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 10 found increased death rates with age. 19, 20 The reasons underpinning this association are likely 205 multifactorial and include high prevalence of multiple comorbidities and immune dysfunction. In 206 our cohort, high rates of multiple comorbidities including hypertension, diabetes, congestive 207 heart failure, prior stroke and dementia were present in patients’ ≥60 years and were associated 208 with death in bivariate analysis. These comorbidities have been found in other studies to be 209 common among patients with COVID-19 and their association with progression to severe disease 210 has led to their inclusion as criteria for monoclonal antibody therapy and vaccination. 21 211 Additional age related factors related to the increased risk of death in older patients are 212 immunosenescence and inflammaging.22, 23 Immunosenescence refers to a gradual deterioration 213 of the immune system with age which can lead to a decreased protective response to infection 214 and vaccination.24 Inflammaging is a more recent concept and refers to a chronic 215 proinflammatory state that is related to immunosenescence.25 As severe COVID-19 illness is 216 characterized by high levels of proinflammatory cytokines, inflammaging has been proposed as 217 one explanation for the increased risk of severe disease and death among older persons.26 Our 218

demonstrate the presence of more severe disease at presentation with increasing age, as 219 we found persons ≥ 60 years had higher SOFA scores, multifocal disease on chest x-ray, and 220 were more likely to be admitted to the ICU. A recent study also highlights the potential impact 221 of a declining immune system with age. Among a population observational cohort, investigators 222 evaluated rates of reinfection with SARS-CoV-2 and found that protection against repeat 223 infection was only 47% among persons ≥ 65 years versus >80% in the overall cohort. 27 This 224 finding highlights the urgent need to study the durability of immunity following vaccination and 225 to evaluate the utility and need for a booster vaccine among older persons. 226 227 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 11 Our extremely high rate of hospitalizations and death from COVID-19 among residents of LCFs 228 highlights the vulnerability of people residing in such settings to communicable diseases and 229 urges us to do more to prevent this disproportionate burden of disease in LCFs. According to the 230 COVID-Tracking Project, persons living in LCFs represent 1% of the US population, 5% of all 231 COVID-19 cases, and account for an alarming 34% of US COVID-19 deaths with rates varying 232 from 15-69% depending on the state.28 A combination of high risk patients and high risk setting 233 are likely responsible for such a high rate of death among LCF residents with COVID-19. As 234 discussed in the above paragraph, increasing age puts LCF residents at higher risk of severe 235 disease. Additionally, older persons in LCFs versus those living in the community are more 236 likely to have multiple comorbidities including physical and cognitive impairments that place 237 them at higher risk of severe disease and death due to COVID-19.29 The disproportionate burden 238 of COVID-19 at LCFs has led to increased attention and scrutiny of their care and availability of 239 resources including staffing and personal protective equipment. Pertinent to our findings is a 240 report highlighting the lack of adequate staffing and resource at a local LCF leading to decreased 241 quality of care and high COVID-19 transmission among residents.30 The COVID-19 pandemic 242 has made it clear that we need to improve resources for LCFs to enable them to provide 243 improved care for their residents. Evidence to support the need for more resources includes data 244 finding adequate nurse staffing is one of the strongest factors correlated with improved COVID-245 19 control and strengthening infection control measures and universal testing can decrease 246 COVID-19 related mortality in LCFs. 31,32 The high rate of disease and death due to COVID-19 247 among residents clearly justifies the prioritization of LCF residents and staff for vaccination; 248 however, despite high rates of vaccination reported among residents early rates of vaccination of 249 staff was only 38%.33 More needs to be done to increase vaccine update among healthcare staff 250 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 12 to prevent disease among LCFs and also to prevent transmission of COVID-19 from LCFs to the 251 community.34 Additionally, the pandemic made us more of aware of our responsibility as a 252 society to take care of our elders, and we as healthcare providers recognize that we have our 253 moral imperative to advocate for the health residents of LCF as they cannot often do so 254 themselves and that we need to take more purposeful action. Beyond being the right and ethical 255 course of action, by advocating for and helping implement improved health systems in LCFs, we 256 will be better prepared as a society us to prevent spread of the current COVID-19 pandemic, 257 SARs-CoV-2 variants that arise,35 and future respiratory virus pandemics. 258 259

260 This study had important limitations. The demographics of the catchment area of this hospital 261 may limit generalizability of our findings. However, these limitations may be balanced by 262 enrichment for potentially under-represented groups, which may be informative for future 263 COVID-19 health disparities research. Given our study period is limited to the first wave of the 264 pandemic, our high death rate may have been due in part to diagnostic delays and lack of 265 available treatments for severe COVID-19. However, current data indicates death rates remain 266 high among older adults and that this population still contributes to the majority of COVID-19 267 associated mortality. 36 268 269

270 Our results confirm other reports that the burden of COVID-19 associated death is occurring 271 among older adults living in LCFs, and adds evidence to the growing call for better healthcare 272 infrastructure in such settings. With the expected substantial growth of the ≥ 60 population over 273 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 13 the next few decades37 it is imperative that we put in place improved preventive and treatment 274 measures to protect our elderly population. 275 276

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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 18 Nursing Homes - West Virginia, April 21-May 8, 2020. MMWR Morb Mortal Wkly Rep 388 69: 1177-1179. 389 33. Gharpure R, Guo A, Bishnoi CK, Patel U, Gifford D, Tippins A, Jaffe A, Shulman E, 390 Stone N, Mungai E, Bagchi S, Bell J, Srinivasan A, Patel A, Link-Gelles R, 2021. Early 391 COVID-19 First-Dose Vaccination Coverage Among Residents and Staff Members of 392 Skilled Nursing Facilities Participating in the Pharmacy Partnership for Long-Term Care 393 Program - United States, December 2020-January 2021. MMWR Morb Mortal Wkly Rep 394 70: 178-182. 395 34. Chen MK, Chevalier JA, Long EF, 2021. Nursing home staff networks and COVID-19. 396 Proc Natl Acad Sci U S A 118. 397 35. Krutikov M, Hayward A, Shallcross L, 2021. Spread of a Variant SARS-CoV-2 in Long-398 Term Care Facilities in England. N Engl J Med. 399 36. Chidambaram P, Garfield R, 2021. Patterns in COVID-19 Cases and Deaths in Long-400 Term Facilities in 2020. Available at: https://www.kff.org/coronavirus-covid-19/issue-401 brief/patterns-in-covid-19-cases-and-deaths-in-long-term-care-facilities-in-2020/. 402 Accessed February 12, 2021. 403 37. Mark Mather, Linda A. Jacobsen, and Kelvin M. Pollard, “Aging in the 404 United States,” Population Bulletin 70, no. 2 (2015). 405 406 407 408 409 410 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 19 Table 1. Demographic and Medical Characteristics of Hospitalized Patients with COVID-19 by 411 Mortality Status 412 Alive (N=307) Died (N=53) Total (N=360) p Age category, years < 0.001 /=80 19 (6%) 15 (28%) 34 (9%) Female 143 (47%) 16 (30%) 159 (44%) 0.026 Race 0.519 Black 240 (78%) 46 (87%) 286 (80%) White 54 (18%) 6 (11%) 60 (17%) Other 4 (1%) 0 (0%) 4 (1%) Hispanic 38 (13%) 4 (8%) 42 (12%) 0.314 Housing type < 0.001 Correctional facility 14 (5%) 0 (0%) 14 (4%) Homeless/shelter 17 (6%) 0 (0%) 17 (5%) Long term health facility 7 (2%) 1 (2%) 8 (2%) Nursing home 59 (19%) 39 (74%) 98 (27%) Stable Home 207 (68%) 13 (25%) 220 (61%) BMI (kg/m2) categories 0.288 <18.5 22 (7%) 4 (8%) 26 (7%) 18.5-24.9 77 (26%) 20 (38%) 97 (28%) 25-29.9 82 (28%) 13 (25%) 95 (27%) ≥30 115 (39%) 15 (29%) 130 (37%) Hypertension 191 (62%) 45 (85%) 236 (66%) 0.001 Diabetes mellitus 0.004 IDDM 43 (14%) 4 (8%) 47 (13%) NIDDM 53 (17%) 11 (21%) 64 (18%) Congestive heart failure 42 (14%) 13 (25%) 55 (15%) 0.037 Coronary artery disease 27 (9%) 5 (10%) 32 (9%) 0.853 Stroke 61 (20%) 26 (49%) 87 (24%) < 0.001 Dementia 47 (15%) 29 (55%) 76 (21%) < 0.001 Chronic kidney disease 0.003 Yes 29 (9%) 11 (21%) 40 (11%) Yes, on dialysis 25 (8%) 1 (2%) 26 (7%) Cirrhosis 3 (1%) 1 (2%) 4 (1%) 0.562 COPD 17 (6%) 5 (9%) 22 (6%) 0.274 Asthma 26 (8%) 2 (4%) 28 (8%) 0.239 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 20 Structural lung disease 4 (1%) 1 (2%) 5 (1%) 0.737 OSA/OHS 15 (5%) 4 (8%) 19 (5%) 0.675 Malignancy 0.783 Current 10 (3%) 1 (2%) 11 (3%) Prior 9 (3%) 1 (2%) 10 (3%) HIV 13 (4%) 0 (0%) 13 (4%) 0.284 *BMI, body mass index; IDDM, insulin dependent diabetes mellitus; NIDDM, non-insulin dependent 413 diabetes mellitus; COPD, chronic obstructive pulmonary disease; OSA/OHS, obstructive sleep 414 apnea/obesity hypoventilation syndrome; HIV, human immunodeficiency virus 415 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 21 Table 2. Clinical Characteristics of Hospitalized Patients with COVID-19 by Mortality Status 416 417 Alive (N=307) Died (N=53) Total (N=360) p SOFA Risk Estimates, Mean (SD) SOFA score 2 (2) 5 (3) 2 (2) <0.001 SOFA-predicted mortality 0.063 (0.084) 0.191 (0.119) 0.079 (0.099) <0.001 qSOFA score 1.069 (0.876) 2.098 (0.855) 1.229 (0.099) <0.001 qSOFA mortality category, N (%) <0.001 High risk 82 (30%) 37 (73%) 119 (36%) Not high risk 195 (70%) 14 (27%) 209 (64%) Admission Level of Care < 0.001 Discharged from emergency department 67 (22%) 2 (4%) 69 (19%) General 185 (60%) 20 (38%) 205 (57%) Intensive 21 (7%) 21 (40%) 42 (12%) Intermediate 34 (11%) 10 (19%) 44 (12%) Highest Level of Care < 0.001 Emergency department 67 (22%) 2 (4%) 69 (19%) General 169 (55%) 8 (15%) 177 (49%) Intensive 34 (11%) 35 (67%) 69 (19%) Intermediate 36 (12%) 7 (13%) 43 (12%) Hospital days, Mean (SD) 9 (14) 11 (8) 9 (13) 0.371 High flow nasal cannula 22 (7%) 24 (45%) 46 (13%) < 0.001 Endotracheal intubation 26 (8%) 30 (57%) 56 (16%) < 0.001 Renal replacement therapy < 0.001 Continuous 4 (1%) 6 (11%) 10 (3%) Intermittent 11 (4%) 3 (6%) 14 (4%) Hospital-Acquired Infection 16 (5%) 2 (4%) 18 (5%) 0.897 Discharge disposition detail < 0.001 AMA 4 (1%) 0 (0%) 4 (1%) Died 0 (0%) 31 (58%) 31 (9%) Home 232 (76%) 0 (0%) 232 (64%) Hospice 0 (0%) 22 (42%) 22 (6%) Long-term Acute Care 3 (1%) 0 (0%) 3 (1%) Nursing Home/Rehabilitation Facility 64 (21%) 0 (0%) 64 (18%) Transfer to the hospital 4 (1%) 0 (0%) 4 (1%) All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 22 New or increased oxygen requirement at discharge/death 13 (4%) 46 (87%) 59 (16%) < 0.001 New HD requirement at discharge/death 1 (0%) 6 (11%) 7 (2%) < 0.001 SD, standard deviation; qSOFA, quick Sequential Organ Failure Assessment; HD, hemodialysis 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 23 Table 3. Demographic and Medical Characteristics of Hospitalized Patients with COVID-19 by 440 Age Category 441 442 <60 (N=190) ≥60 (N=170) Total (N=360) p Hypertension 89 (47%) 147 (86%) 236 (66%) < 0.001 Diabetes mellitus 0.028 IDDM 22 (12%) 25 (15%) 47 (13%) NIDDM 26 (14%) 38 (22%) 64 (18%) Congestive heart failure 18 (9%) 37 (22%) 55 (15%) 0.001 Coronary artery disease 10 (5%) 22 (13%) 32 (9%) 0.010 Stroke 19 (10%) 68 (40%) 87 (24%) < 0.001 Dementia 6 (3%) 70 (41%) 76 (21%) < 0.001 Chronic kidney disease < 0.001 Yes 10 (5%) 30 (18%) 40 (11%) Yes, on dialysis 9 (5%) 17 (10%) 26 (7%) Cirrhosis 2 (1%) 2 (1%) 4 (1%) 0.915 COPD 6 (3%) 16 (9%) 22 (6%) 0.013 Asthma 19 (10%) 9 (5%) 28 (8%) 0.096 Structural lung disease 2 (1%) 3 (2%) 5 (1%) 0.564 OSA/OHS 9 (5%) 10 (6%) 19 (5%) 0.571 Malignancy 0.023 Current 3 (2%) 8 (5%) 11 (3%) Prior 2 (1%) 8 (5%) 10 (3%) HIV 0.467 Yes 8 (4%) 5 (3%) 13 (4%) Radiology CXR performed 174 (92%) 166 (98%) 340 (94%) 0.012 Atelectasis 45 (26%) 58 (35%) 103 (30%) 0.069 Bilateral Opacities, not effusions 73 (42%) 80 (48%) 153 (45%) 0.248 No Cavity/abscess 174 (100%) 166 (100%) 340 (100%) 0.664 Consolidation 10 (6%) 14 (8%) 24 (7%) 0.334 Interstitial 15 (9%) 23 (14%) 38 (11%) 0.130 Mass/mass-like 1 (1%) 0 (0%) 1 (0%) 0.328 Multifocal 19 (11%) 35 (21%) 54 (16%) 0.010 Pleural effusion 10 (6%) 17 (10%) 27 (8%) 0.121 Reticulonodular 4 (2%) 2 (1%) 6 (2%) 0.440 443 *BMI, body mass index; IDDM, insulin dependent diabetes mellitus; NIDDM, non-insulin dependent 444 diabetes mellitus; COPD, chronic obstructive pulmonary disease; OSA/OHS, obstructive sleep 445 apnea/obesity hypoventilation syndrome; HIV, human immunodeficiency virus 446 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 24 447 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 25 Table 4. Clinical Characteristics of Hospitalized Patients with COVID-19 by Age Category 448 449 <60 Years- Old (N=190) ≥ 60 Years-Old (N=170) Total (N=360) p Admission Level of Care < 0.001 Discharged from emergency department 61 (32%) 8 (5%) 69 (19%) General 102 (54%) 103 (61%) 205 (57%) Intensive 10 (5%) 32 (19%) 42 (12%) Intermediate 17 (9%) 27 (16%) 44 (12%) Highest Level of Care < 0.001 Emergency department 61 (32%) 8 (5%) 69 (19%) General 91 (48%) 86 (51%) 177 (49%) Intensive 21 (11%) 48 (29%) 69 (19%) Intermediate 17 (9%) 26 (15%) 43 (12%) Hospital days, Mean (SD) 6 (10) 13 (15) 9 (13) < 0.001 ICU days, Mean (SD) 186 (803) 11 (13) 64 (443) 0.132 SOFA Risk Estimates, Mean (SD) SOFA score 1 (2) 3 (2) 2 (2) < 0.001 SOFA-predicted mortality 0.042 (0.076) 0.113 (0.105) 0.079 (0.099) < 0.001 qSOFA score 1 (1) 2 (1) 1 (1) < 0.001 qSOFA mortality category, N (%) < 0.001 High risk 28 (17.8%) 91 (53.2%) 119 (36.3%) Not high risk 129 (82.2%) 80 (46.8%) 209 (63.7%) High flow nasal cannula 13 (7%) 33 (20%) 46 (13%) < 0.001 Endotracheal intubation 19 (10%) 37 (22%) 56 (16%) 0.002 Renal replacement therapy 0.395 Continuous 6 (3%) 4 (2%) 10 (3%) Intermittent 5 (3%) 9 (5%) 14 (4%) Hospital-Acquired Infection 0.235 Yes 8 (4%) 10 (6%) 18 (5%) Unknown 9 (5%) 3 (2%) 12 (3%) Discharge disposition detail < 0.001 AMA 4 (2%) 0 (0%) 4 (1%) Died 7 (4%) 24 (14%) 31 (9%) Home 168 (88%) 64 (38%) 232 (64%) Hospice 0 (0%) 22 (13%) 22 (6%) Long-term Acute Care 1 (1%) 2 (1%) 3 (1%) All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint 26 Nursing Home/Rehabilitation Facility 8 (4%) 56 (33%) 64 (18%) Transfer to the hospital 2 (1%) 2 (1%) 4 (1%) New or increased oxygen requirement at discharge/death 12 (6%) 47 (28%) 59 (16%) < 0.001 New HD requirement at discharge/death 5 (3%) 2 (1%) 7 (2%) 0.315 SD, standard deviation; qSOFA, quick Sequential Organ Failure Assessment; HD, hemodialysis; AMA, 450 against medical advice 451 452 453 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted June 17, 2022. ; https://doi.org/10.1101/2022.06.16.22276514doi: medRxiv preprint