Public Health

Health system supplies crucial early data on COVID-19 response

Some 1.5 million people have been diagnosed with COVID-19 in the U.S., and about 352,000 of those patients were in the state of New York. Researchers with the Northwell Health system, which has provided care for more than 20% of COVID-19 patients in the state, have helped physicians learn who these patients are.

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The academic health system, which had discharged more than 10,500 COVID-19 patients as of May 15, collected data on the 5,700 COVID-19 patients who were admitted to 12 of its hospitals between March 1 and April 4.

The hospitals are in New York City, Long Island and Westchester County and 11 of the 12 are teaching institutions. There are 11 million people in the system’s diverse service area and the study, published in JAMA, helps identify the characteristics, baseline comorbidities, clinical presentation, and outcomes of COVID-19 patients hospitalized in the U.S.

“The findings are sobering,” wrote JAMA Health Forum editors John Ayanian, MD, director of the University of Michigan’s Institute for Healthcare Policy and Innovation; and Melinda Buntin, PhD, chair of the Vanderbilt School of Medicine’s department of health policy. 

“The authors draw on detailed clinical data from electronic health records, including vital signs, laboratory tests, medications, and comorbid conditions, in a racially and ethnically diverse cohort (23% African American; 23% Hispanic; 19% with a preferred language other than English),” they wrote in an Editor’s Comment column. “Given all these strengths, and that New York has experienced the largest COVID-19 outbreak in the U.S., this study is a valuable contribution to the growing medical literature on COVID-19.”

They added that the patient-use rates for intensive care, 14.2%; mechanical ventilation 12.2%; and kidney replacement therapy, 3.2%; “can guide other U.S. regions in planning for critical care needs.”

Other findings included:

  • Median age of the patients was 63.
  • There was roughly a 60-40 split between male and female patients.
  • Their most common comorbidities were hypertension, 56.6%; obesity, 41.7%; and diabetes, 33.8%.

The study notes that comorbidities were a key factor in the acuity of the disease. Patients with diabetes, for example, were more likely to have received invasive mechanical ventilation, received treatment in the intensive care unit (ICU), or developed acute kidney disease.

But the study also raises questions.

“We are particularly struck that there are no cardinal presenting symptoms—no way to tell immediately who has COVID-19 based on their symptoms when they arrive—nor any lab values that can clearly help us know who will develop severe respiratory distress or respiratory failure,” said study co-author Karina W. Davidson, PhD, Northwell Health’s senior vice president for research and dean of academic affairs.

About one-third of all patients presented with a fever at triage, 17.3% had a high respiratory rate and 27.8% received supplemental oxygen.

“As the virus spreads in other parts of the country, we want other clinicians to recognize that many variants of symptom and lab-value presentations are still consistent with COVID-19 disease,” Davidson added. “That means that using fever or another single symptom or sign is not sufficient to determine if someone has COVID-19 disease. Every patient with flu-like symptoms should be considered to be COVID-19 positive, until proven otherwise.”

On average, patients were discharged after four days. Most patients—3,066 (53.8%)—were still in the hospital when the study concluded, while 2,081 (35.5%) were discharged, and 553 died (9.7%). Of those discharged, 94.1% went home while the others were transferred to a nursing home or other care facility. Forty-five patients (2.2%) were readmitted, and the median readmission time was three days. Mortality rates were higher for male patients than female in every age group.

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Research will go on

The short duration of the study meant clinical outcome data was still pending for many patients.  For example, out of the 1,151 (20.2%) patients who needed ventilators, 38 were discharged, 282 died, but 831 remained in hospital. Follow-up research has already begun.

Davidson said plans for future studies include:

  • Following up on COVID-19 patients’ symptom presentation, treatment course and outcome.
  • Examining the course of disease for patients who were managed outside of the hospital.
  • Following up with COVID-19 patients to obtain psychological and physical well-being information. This includes studying whether patients need long-term monitoring or treatment for organ damage or other medical consequences.
  • Examining data from health care workers who have received antibody testing (27,000 so far) to gain a better understanding of COVID-19 symptoms.

During the COVID-19 public health emergency, collecting patient race and ethnicity data has been a challenge for everyone.

Davidson said asking every patient to self-identify their racial, ethnic and gender identity and to enter that information into the electronic health record is part of Northwell’s effort to remove health inequities and disparities.

“We saw that the patients presenting with COVID-19 disease represented our general patient population, which is one of the most diverse in the country,” she said. “We are now investigating the outcomes for those with identified social needs and those who are from higher poverty districts.”

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Resiliency, teamwork in action

The resiliency of the Northwell staff was illustrated by how 1,200 new acute care beds were added during the period of the study. In addition to this nimbleness, Northwell President and CEO Michael Dowling has remarked on the “enhanced interdisciplinary nature” of care teams working together in the ICU and elsewhere. 

“The little silos have been completely broken down over the last five or six weeks,” Dowling said. “We have got to make sure we keep them broken down.”

Davidson said the JAMA study was one example of this resiliency and teamwork in action.

“It’s important to first understand why we published our initial study findings,” she said. “We were one of the first health care systems in the country to encounter an influx of COVID-19 patients. We felt it was our duty to help other clinicians and hospitals know what to expect.”

This sense urgency led to the formation of a consortium of more than 500 clinicians, scientists, statisticians, laboratory professionals, and trainees. They created working groups to clean data, extract information into case report forms, merge data from various data systems, and bank biospecimens from patients.  

“Across the board, every employee volunteered to ensure every task was completed,” Davidson said. “We had volunteers who worked 18 hours a day, through weekends, so that we, as a consortium, could get this work done.” 

She noted that one clinician symptomatic with COVID-19 worked from home, but still participated in every call and trained surgical residents in pulling data for the study. There were also emergency department physicians who called in for the meetings after finishing their 18-hour shifts. 

This spirit continues with 90 medical students who have volunteered to extract data for the first follow-up study mentioned above. 

“All of these efforts will require continued hard work from our researchers, scientists, physicians, and others who are committed to sharing what we are learning, so that we can help clinicians across the country successfully manage this devastating disease, and ultimately help save as many lives as possible,” Davidson said.