Characteristics and Clinical Outcomes of Adult Patients Hospitalized with COVID-19 — Georgia, March 2020

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SARS-CoV-2, the novel coronavirus that causes coronavirus disease 2019 (COVID-19), was first detected in the United States during January 2020 (1). Since then, >980,000 cases have been reported in the United States, including >55,000 associated deaths as of April 28, 2020 (2). Detailed data on demographic characteristics, underlying medical conditions, and clinical outcomes for persons hospitalized with COVID-19 are needed to inform prevention strategies and community-specific intervention messages. For this report, CDC, the Georgia Department of Public Health, and eight Georgia hospitals (seven in metropolitan Atlanta and one in southern Georgia) summarized medical record–abstracted data for hospitalized adult patients with laboratory-confirmed* COVID-19 who were admitted during March 2020. Among 305 hospitalized patients with COVID-19, 61.6% were aged <65 years, 50.5% were female, and 83.2% with known race/ethnicity were non-Hispanic black (black). Over a quarter of patients (26.2%) did not have conditions thought to put them at higher risk for severe disease, including being aged ≥65 years. The proportion of hospitalized patients who were black was higher than expected based on overall hospital admissions. In an adjusted time-to-event analysis, black patients were not more likely than were nonblack patients to receive invasive mechanical ventilation^† (IMV) or to die during hospitalization (hazard ratio [HR] = 0.63; 95% confidence interval [CI] = 0.35–1.13). Given the overrepresentation of black patients within this hospitalized cohort, it is important for public health officials to ensure that prevention activities prioritize communities and racial/ethnic groups most affected by COVID-19. Clinicians and public officials should be aware that all adults, regardless of underlying conditions or age, are at risk for serious illness from COVID-19.

Hospitalized cases were selected to describe patients with severe manifestations of COVID-19 that warranted inpatient management. Data were collected from a convenience sample of 305 patients at seven hospitals in metropolitan Atlanta (five community hospitals, one university hospital, and one public hospital) and one community hospital in southern Georgia. Patients were selected sequentially from lists provided in real time by hospitals from a total of 698 patients aged ≥18 years who were hospitalized with laboratory-confirmed COVID-19 during March 1–March 30, 2020, including stays for observation and deaths in the emergency department. Over a 3-week period, data were abstracted from electronic medical records and recorded using Research Electronic Data Capture software (version 8.8.0; Vanderbilt University) (3). Hospitalizations for patients transferred between participating hospitals or admitted multiple times to the same hospital were analyzed as a single hospitalization. Data on patient race/ethnicity, age, sex, body mass index (BMI), insurance status, residence (e.g., in a long-term care facility), risk factors for severe COVID-19 (based on currently available data and clinical expertise)^§ (4), and outcomes were abstracted from medical records. Race was categorized as black (non-Hispanic) or nonblack (all other racial/ethnic groups), and age was analyzed in three groups: 18–49, 50–64, and ≥65 years. Fisher’s exact tests for proportions and the Wilcoxon rank sum test or the Kruskal-Wallis H test for medians were used to test differences identified in descriptive analyses. Multivariable Cox proportional-hazards analysis was performed on the association between race and time to meeting a composite outcome of IMV or death, adjusting for age, sex, BMI, hospital, admission date, and underlying medical conditions (selected through a stepwise Akaike information criterion approach, which balances a model’s fit against its complexity); censoring was used to account for patients still hospitalized without receiving IMV. P-values <0.05 were considered statistically significant. R statistical software (version 3.6.3; The R Foundation) was used to conduct all analyses.

Among 305 patients hospitalized with COVID-19, the median age was 60 years (range = 23–95 years, interquartile range [IQR] = 46–69 years) (Figure 1); 50.5% of patients were female, and 284 (93%) were hospitalized in metropolitan Atlanta. Data on race/ethnicity were available for 297 (97.4%) patients, among whom, 247 (83.2%) were black, 32 (10.8%) were non-Hispanic white, eight (2.7%) were non-Hispanic Asian or Pacific Islander, and 10 (3.4%) were Hispanic (Figure 2). Median age was not significantly different between black patients (60 years, IQR = 45.5–69.0 years) and nonblack patients (64.5 years, IQR = 44.8–74.0 years). Most patients had private insurance (40.1%) or Medicare (33.4%); 10.9% had Medicaid, and 14.9% were uninsured. Compared with nonblack patients, black patients were more likely to have Medicaid (13.5% versus 0.0%, p = 0.002) but not more likely to be uninsured. Overall, 20 (6.6%) patients resided in long-term care facilities before hospitalization. Current smoking was reported for 5.2% of patients.

Overall, 225 (73.8%) patients had conditions considered high-risk for severe COVID-19 (Table 1). Diabetes was documented in 39.7% of patients. Diabetes was most common in patients aged 50–64 years (46.5%; p = 0.001) but was not significantly more common in black patients than in nonblack patients (41.7% versus 32.0%; p = 0.21). Cardiovascular disease, documented in 25.6% of patients, was more prevalent in those aged ≥65 years (47.0%; p<0.001) but prevalence was similar in black (25.1%) and nonblack patients (30.0%) (p = 0.48). Overall, 20.3% of patients had chronic lung disease, with no significant differences by age or race. Asthma was documented in 10.5% of all patients and chronic obstructive pulmonary disease in 5.2%. Severe obesity (BMI ≥40), present in 12.7% of patients, was most common in those aged 18–49 years (21.8%; p<0.001). Severe obesity did not differ significantly by race, although median BMI was higher in black (31.4 [IQR = 27.6–36.9]) than in nonblack patients (29.6 [IQR = 24.3–32.5]; p = 0.003). Hypertension (not considered a high-risk condition) was documented in 67.5% of patients and was more common among black versus nonblack patients (69.6% versus 54.0%; p=0.047).

Among the 305 hospitalized patients, the median duration of hospitalization was 8.5 days and duration increased with age (Table 2). Intensive care unit (ICU) admission occurred among 119 (39.0%) patients and increased significantly with age group: among patients aged ≥65 years, 53.8% were admitted to an ICU (p<0.001). Overall, 92 (30.2%) patients received IMV, representing 77.3% of those admitted to an ICU.

Among 281 (92.1%) patients who were no longer hospitalized at the time of data abstraction, 48 (17.1%) died. Case fatality among patients aged 18–49 years, 50–64 years, and ≥65 years was 3.4%, 9.8%, and 35.6%, respectively (p<0.001). Black patients were not more likely than were nonblack patients to receive IMV, to die, or to experience the composite outcome of IMV or death (Figure 2). Among patients without high-risk conditions, 22.5% were admitted to the ICU, 15.0% received IMV, and 5.1% died while in the hospital. As of April 24, 2020, 24 (7.9%) patients remained hospitalized, including 14 (58.3%) in the ICU and nine (37.5%) on IMV. Overall, the estimated percentage of deaths among patients who received ICU care ranged from 37.0%, assuming all remaining ICU patients survived, to 48.7%, assuming all remaining ICU patients died. In an adjusted time-to-event analysis of IMV or death as a composite outcome, no significant difference was found between black and nonblack patients (HR = 0.63; 95% CI = 0.35–1.13).

Acknowledgments

William Bornstein, Debra Houry, Brian Manns, CDC COVID-19 Response Clinical Team; Kymmi Cooley; Jessica Hawkins, Glenn Hilburn; Guru Patel; Jonathan Perkins; Chad Robichaux; Keneisha Williams; Tripura Vadlamani; informatics and information technology staff members at collaborating hospitals; health care personnel on the front lines of COVID-19 care in Georgia.

Corresponding author: Brendan Jackson, [email protected], 404-639-0536.

¹CDC COVID-19 Emergency Response; ²Epidemic Intelligence Service, CDC; ³Georgia Department of Public Health; ⁴Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee; ⁵Emory University School of Medicine, Atlanta, Georgia; ⁶Georgia Clinical & Translational Science Alliance, Atlanta, Georgia; ⁷Grady Health System, Atlanta, Georgia; ⁸Phoebe Putney Memorial Hospital, Albany, Georgia; ⁹Emory Decatur Hospital, Decatur, Georgia.

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FIGURE 1. Age distribution of adults hospitalized with COVID–19 (N = 305) — eight hospitals, Georgia, March 2020

Abbreviation: COVID-19 = coronavirus disease 2019.

FIGURE 2. Number of hospitalized patients with COVID-19 (N = 305)* (A) and percentage who received invasive mechanical ventilation or died (B),^† by race/ethnicity^§ — eight hospitals, Georgia, March 2020

Abbreviations: COVID-19 = coronavirus disease 2019; IMV = invasive mechanical ventilation.

* A total of 273 patients had available race/ethnicity data and known hospitalization outcomes.

^† Vertical bars represent 95% confidence intervals for proportions.

^§ Black was defined as non-Hispanic black race/ethnicity; other includes all other racial/ethnic groups.

Abbreviations: BMI = body mass index; COPD = chronic obstructive pulmonary disease; COVID-19 = coronavirus disease 2019; IQR = interquartile range; N/A = not applicable.
* Black was defined as non-Hispanic black race/ethnicity; other includes all other racial/ethnic groups.
^† P-values were calculated using Fisher’s exact tests for proportions.
^§ Eight patients were excluded from race comparisons because race and ethnicity data were missing.
^¶ Age ≥65 years was considered a high-risk condition.
** BMI data were missing for 13 patients.
^§§ Documented conditions included solid organ transplant (eight), human immunodeficiency virus infection (eight), cancer with chemotherapy receipt within the previous year (three), stem cell transplant (three), and leukemia (two); 16 patients were taking immunosuppressive medications.

Abbreviations: COVID-19 = coronavirus disease 2019; ICU = intensive care unit; IQR = interquartile range.
* Black was defined as non-Hispanic black race/ethnicity; other includes all other racial/ethnic groups.
^† Eight patients were excluded from race comparisons because race and ethnicity data were missing.
^§ P-values were calculated using Fisher’s exact tests for proportions and the Wilcoxon rank-sum test or the Kruskal-Wallis H test for medians.
^¶ Continuous variables are presented as median (IQR).
** Among 281 total patients who were no longer hospitalized, 88 (31.3%) were aged 18–49 years, 92 (32.7%) were aged 50–64 years, and 101 (35.9%) were aged ≥65 years; among 273 patients with available race/ethnicity data who were no longer hospitalized, 229 (83.9%) were non-Hispanic black, and 44 (16.1) were of other race/ethnicity.