Thread by @I_mitochondria

An uncomfortable topic:

The health system factor, in contributing to COVID-19 mortality rate in the first quarter of 2020. However, the positive is also to be seen in this study (Anesi et al., 2021) in the application of a system that enabled rapid…

doi.org/10.7326/M20-53…

..frequent real-time iterative updates in sharing of knowledge btn health carers to recognise ineffective and/or dangerous interventions and where health carers see positive effective measures, in-order to adjust standard operating procedures (SOPs) to improve patient outcomes...

As a result, mortality rate decreased over time despite stable patient characteristics.

Retrospective cohort study in patients admitted to ICU investigating:

1) all-cause 28-day in-hospital mortality rate,

2) all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions, between patients admitted in the first and last 15-day periods,…

….from 1 March to 11 May 2020; with the last day of follow-up 1 July 2020.

The primary outcome:

➡️ all-cause 28-day in-hospital mortality, patients either dying in hospital or surviving to hospital discharge by day 28, or having at least 28 days of in-hospital follow-up.

Secondary outcome:

All-cause death at any time, hospital length of stay, ICU length of stay, mechanical ventilation (MV) duration, recovery from acute renal replacement therapy, and tracheostomy, use of the complete follow-up time in the data set was reported.

Linear and logistic regression analysis investigated:
➡️ was ICU admission date associated with rates of mechanical ventilation (MV) use (unadjusted and adjusted for Pao2–FIo2 ratio) and with patient-level factors.

1470 patients with COVID-19 admitted to the 5 study hospitals from 1 March to 11 May 2020, 480 (32.7%) were admitted to ICU.

•n = 468 (97.5%) met inclusion criteria, with median age of 65 years (interquartile range [IQR], 54 to 74 years),

•male, 57.7%
•black, 52.8%
•high comorbidity burden, 71.8% (with ≥2 points on the Charlson Comorbidity Index).
•319 (68.2%) received mechanical ventilation (MV).

The proportion of patients treated with mechanical ventilation (MV) decreased over time, from 85.7% (95% CI, 77.1% to 94.4%) to 54.2% (CI, 44.2% to 64.1%) between the first and last 15-day periods.

Compared with the first 15-day period, the odds ratio (OR) for receiving MV decreased stepwise across the second (OR, 0.49 [CI, 0.22 to 1.07]; P = 0.074), third (OR, 0.29 [CI, 0.13 to 0.64]; P = 0.002), and fourth (OR, 0.20 [CI, 0.09 to 0.44]; P < 0.001) 15-day periods.

n = 140, patient outcome all-cause 28-day in-hospital mortality rate was:

37.0% among those who received mechanical ventilation (MV),
14.8% among those who did not.

A mechanism for improved mortality over time in the face of unchanging acuity, was better adherence to evidence-based standard-of-care therapies for critical illness—such as averting intubation.

Rates of mechanical ventilation (MV) use decreased over time.

Decreasing intubation, using non-invasive oxygenation improved patient outcome.

Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods, patient acuity and other factors did not change.