Characteristics and outcome of COVID-19 patients admitted to the ICU: a nationwide cohort study on the comparison between the consecutive stages of the COVID-19 pandemic in the Netherlands, an update
Authors: Termorshuizen Fabian , Dongelmans Dave A. , Brinkman Sylvia , Bakhshi-Raiez Ferishta , Arbous M. Sesmu , de Lange Dylan W. , van Bussel Bas C. T. , de Keizer Nicolette F. ,   the Dutch COVID-19 Research Consortium, Barnas M.G.W. , Boer D.P. , Bosman R.J. , Brunnekreef G.B. , de Graaff M. , de Jong R.M. , de Meijer A.R. , de Ruijter W. , de Waal R. , Dijkhuizen A. , Dormans T.P.J. , Draisma A. , Drogt I. , Eikemans B.J.W. , Elbers P.W.G. , Epker J.L. , Erkamp M.L. , Festen-Spanjer B. , Frenzel T. , Georgieva L. , Gritters N.C. , Hené I.Z. , Hendriks S.H.A. , Hoeksema M. , Holtkamp J.W.M. , Hoogendoorn M.E. , Jacobs C.J.G.M. , Janssen I.T.A. , Kieft H. , Koetsier M.P. , Koning T.J.J. , Kreeftenberg H. , Kusadasi N. , Lens J.A. , Lutisan J.G. , Mehagnoul-Schipper D.J. , Moolenaar D. , Nooteboom F. , Pruijsten R.V. , Ramnarain D. , Reidinga A.C. , Rengers E. , Rijkeboer A.A. , Rijpstra T. , Rozendaal F.W. , Schnabel R.M. , Silderhuis V.M. , Spijkstra J.J. , Spronk P.E. , Urlings-Strop L.C. , van den Berg A.E. , van den Berg R. , van der Horst I.C.C. , Van der Voort P.H.J. , van Driel E.M. , van Gulik L. , van Iersel F.M. , van Lieshout M. , van Oers J.A.H. , van Slobbe-Bijlsma E.R. , van Tellingen M. , Verbiest D.P. , Versluis D.J. , Verweij E. , de Vrolijk-Mos M. , Wesselink R.M.J. 
Published: January 2024

Abstract
Background
Previously, we reported a decreased mortality rate among patients with COVID-19 who were admitted at the ICU during the final upsurge of the second wave (February–June 2021) in the Netherlands. We examined whether this decrease persisted during the third wave and the phases with decreasing incidence of COVID-19 thereafter and brought up to date the information on patient characteristics.

Methods
Data from the National Intensive Care Evaluation (NICE)-registry of all COVID-19 patients admitted to an ICU in the Netherlands were used. Patient characteristics and rates of in-hospital mortality (the primary outcome) during the consecutive periods after the first wave (periods 2–9, May 25, 2020–January 31, 2023) were compared with those during the first wave (period 1, February–May 24, 2020).

Results
After adjustment for patient characteristics and ICU occupancy rate, the mortality risk during the initial upsurge of the third wave (period 6, October 5, 2021–January, 31, 2022) was similar to that of the first wave (ORadj = 1.01, 95%-CI [0.88–1.16]). The mortality rates thereafter decreased again (e.g., period 9, October 5, 2022–January, 31, 2023: ORadj = 0.52, 95%-CI [0.41–0.66]). Among the SARS-CoV-2 positive patients, there was a huge drop in the proportion of patients with COVID-19 as main reason for ICU admission: from 88.2% during the initial upsurge of the third wave to 51.7%, 37.3%, and 41.9% for the periods thereafter. Restricting the analysis to these patients did not modify the results on mortality.

Conclusions
The results show variation in mortality rates among critically ill COVID-19 patients across the calendar time periods that is not explained by differences in case-mix and ICU occupancy rates or by varying proportions of patients with COVID-19 as main reason for ICU admission.
The consistent increase in mortality during the initial, rising phase of each separate wave might be caused by the increased virulence of the contemporary virus strain and lacking immunity to the new strain, besides unmeasured patient-, treatment- and healthcare system characteristics.