Mortality in COVID-19 is not merely a question of resource availability
Authors: Tobias Becher, Inéz Frerichs
Journal: The Lancet Respiratory Medicine (2020)

After the initial outbreak of COVID-19 in Wuhan, China, in December, 2019, the first 16 cases of COVID-19 in Germany were identified between Jan 27, and Feb 11, 2020.1Böhmer MM Buchholz U Corman VM et al.Investigation of a COVID-19 outbreak in Germany resulting from a single travel-associated primary case: a case series.Lancet Infect Dis. 2020; (published online May 15.)https://doi.org/10.1016/S1473-3099(20)30314-5Summary Full Text Full Text PDF PubMed Scopus (309) Google Scholar Although these 16 cases were contained successfully, further introductions of COVID-19 into Germany by tourists returning from Austria and super-spreading events, such as the carnival festivities in mid-February, led to a nationwide spread of the virus within a few weeks. Seeing the developments in Italy and Spain, with an exponential surge of intensive care unit (ICU) admissions, a rapidly increasing death toll, and partial overwhelming of local health-care systems, German authorities introduced physical distancing and other lockdown measures in the second half of March, 2020, at a time when fewer than 1000 of more than 30 000 ICU beds were occupied with patients with COVID-19. As a result of these measures, the German health-care system, which has one of the highest numbers of ICU beds per capita worldwide,2Organisation for Economic Co-operation and DevelopmentBeyond containment: health systems responses to COVID-19 in the OECD.https://read.oecd-ilibrary.org/view/?ref=119_119689-ud5comtf84&title=Beyond_Containment:Health_systems_responses_to_COVID-19_in_the_OECDDate: April 16, 2020Date accessed: July 14, 2020Google Scholar has not been overwhelmed by the COVID-19 pandemic, with at least 40% of all registered ICU beds available even at the height of the epidemic in April, 2020. This situation offers the opportunity to study the outcomes of a large group of patients with COVID-19 in a health-care system with sufficient resources for treating every patient with all therapeutic options of modern intensive care medicine. To this end, Christian Karagiannidis and colleagues3Karagiannidis C Mostert C Hentschker C et al.Case characteristics, resource use, and outcomes of 10 021 patients with COVID-19 admitted to 920 German hospitals: an observational study.Lancet Respir Med. 2020; (published online July 28.)https://doi.org/10.1016/S2213-2600(20)30316-7Summary Full Text Full Text PDF PubMed Scopus (561) Google Scholar evaluated a cohort comprising 10 021 patients diagnosed with COVID-19 who were admitted to 920 hospitals across Germany between Feb 26, 2020, and April 19, 2020. Data were retrieved from a large group of German statutory health insurance funds, accounting for approximately one-third of the total population. Despite the availability of intensive care resources for all patients, Karagiannidis and colleagues found a high mortality of 22% in hospitalised patients (2229 of 10 021). The median age of patients in the studied cohort of 72 years (IQR 57–82) was higher than in other published COVID-19 cohorts. For example, a median age of 63 years (52–75) was reported in the New York cohort,4Richardson S Hirsch JS Narasimhan M et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6479) Google Scholar which comprised 2634 patients with definite outcomes of discharge or death, and a median age of only 47 years (35–58) was reported in an early Chinese cohort.5Guan W-J Ni Z-Y Hu Y et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (20381) Google Scholar Albeit in an older population, the mortality reported by Karagiannidis and colleagues was similar to that reported in New York (21%),4Richardson S Hirsch JS Narasimhan M et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6479) Google Scholar but was higher than that in the younger patients in China (1·4%).5Guan W-J Ni Z-Y Hu Y et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (20381) Google Scholar Karagiannidis and colleagues found a high mortality of 72% (280 of 388) in patients aged 80 years and older who required mechanical ventilation. An even higher mortality of 97% was reported for patients older than 65 years and requiring mechanical ventilation in the New York cohort.4Richardson S Hirsch JS Narasimhan M et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6479) Google Scholar The proportion of patients requiring mechanical ventilation was similar in the German and New York cohorts (17% and 20%, respectively). Of note, the median length of hospital stay differed between these two cohorts (10 days [5–19] in the German cohort and 4 days [2–7] in the New York cohort), which might reflect the different strains on the two health-care systems. Karagiannidis and colleagues' findings support the strong association of poor outcomes with demographic characteristics (older age and male sex) and comorbidities described in previous studies,4Richardson S Hirsch JS Narasimhan M et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6479) Google Scholar, 5Guan W-J Ni Z-Y Hu Y et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (20381) Google Scholar with a mortality rate of up to 73% in patients requiring both mechanical ventilation and dialysis. Although the high mortality observed in this study could be considered disheartening, the data presented by Karagiannidis and colleagues were obtained during the first wave of COVID-19, when reliable data on the therapeutic effectiveness of potential treatments were scarce. Interventions such as early administration of remdesivir to patients not yet requiring mechanical ventilation6Beigel JH Tomashek KM Dodd LE et al.Remdesivir for the treatment of Covid-19—preliminary report.N Engl J Med. 2020; (published online May 22.)https://doig.org/10.1056/NEJMoa2007764Crossref Scopus (4986) Google Scholar and administration of dexamethasone later in the course of the disease to patients requiring supplemental oxygen or on mechanical ventilation7The RECOVERY Collaborative GroupDexamethasone in hospitalized patients with COVID-19—preliminary report.N Engl J Med. 2020; (published online July 17.)https://doi.org/10.1056/NEJMoa2021436Crossref Scopus (6997) Google Scholar could improve outcomes for future patients. A histopathological study has shown a high prevalence of alveolar capillary microthrombi in patients with COVID-19,8Ackermann M Verleden SE Kuehnel M et al.Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19.N Engl J Med. 2020; 383: 120-128Crossref PubMed Scopus (3865) Google Scholar which is consistent with an elevation of ventilated but not perfused lung units observed in mechanically ventilated patients with COVID-19-associated acute respiratory distress syndrome.9Mauri T Spinelli E Scotti E et al.Potential for lung recruitment and ventilation-perfusion mismatch in patients with the acute respiratory distress syndrome from coronavirus disease 2019.Crit Care Med. 2020; 48: 1129-1134Crossref PubMed Scopus (156) Google Scholar Conceivably, anticoagulant treatment could become an important therapeutic measure for treating patients with severe disease in the future.10Tang N Bai H Chen X Gong J Li D Sun Z Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy.J Thromb Haemost. 2020; 18: 1094-1099Crossref PubMed Scopus (2432) Google Scholar The optimal timing of intubation is still being debated, as is the optimal strategy for adjusting positive end-expiratory pressure in patients on invasive mechanical ventilation. Despite these potential therapeutic advances, COVID-19 remains a life-threatening disease, even if sufficient resources for maximum intensive care therapy are available for all patients affected by the disease. We declare no competing interests. Case characteristics, resource use, and outcomes of 10 021 patients with COVID-19 admitted to 920 German hospitals: an observational studyIn the German health-care system, in which hospital capacities have not been overwhelmed by the COVID-19 pandemic, mortality has been high for patients receiving mechanical ventilation, particularly for patients aged 80 years or older and those requiring dialysis, and has been considerably lower for patients younger than 60 years. Full-Text PDF