In this large cohort of patients with COVID-19 and underlying comorbid conditions who were sent home to self-isolate, the majority were younger females of African American descent with an average body mass index within the obesity class I range and never smokers. The patients eventually admitted to the hospital were older, had higher BMI (obesity class II) and were more likely male. The literature on the demographics of patients with COVID-19 at high risk for severe disease who are sent home to self-isolate is limited. According to the Michigan Department of Health and Human Services, overall cases aged 30-59 constitute 59% of the affected population with 53% females and 33% are African-Americans. Currently, African Americans make up 14% of the population in Michigan and in our analysis they have been disproportionately affected by COVID-19.13
Our study also found that the most common symptoms reported upon ED presentation were: fever, dyspnea, rhinorrhea, cough, myalgia, fatigue and chills. These results are consistent with WHO findings of fever, fatigue, and dry cough as the most common COVID-19 symptoms, along with previously reported less common symptoms including myalgias, nasal congestion, rhinorrhea, sore throat, and diarrhea.14 Among 138 hospitalized patients with COVID-19 pneumonia in Wuhan, the most common clinical features at the onset of illness were also fever (99%), fatigue (70%), dry cough (59%), anorexia (40%), myalgias (35%), dyspnea (31%), and sputum production (27%).15 It appears that the inpatient and outpatient commonly reported symptoms are similar.
Diabetes mellitus was the most common comorbidity in our cohort, followed by hypertension, hyperlipidemia and obstructive sleep apnea. Although a requirement for testing included comorbid conditions, more than a third of the patients from our cohort did not have evidence of these medical problems in our database. This finding could have been because the cohort was truly healthier than the previously reported inpatient cohort and did not fully meet MDHHS criteria and/or their medical records were incomplete with missing data about risk factors for severe disease. Comparing the patients who were eventually admitted to the hospital with the patients who never required an admission, hypertension, diabetes mellitus, prediabetes, OSA, COPD, hyperlipidemia, cognitive impairment or dementia, CKD and cancer were associated with more severe disease requiring hospital admission. Worse outcomes have been reported before in patients with COPD, diabetes mellitus, hypertension, and malignancy.16 Furthermore, a cumulative increased risk of severe disease has been reported with an increase in the number of medical comorbidities. There are other comorbidities that are more unique to our patient population, and their impact on disease progression is less understood. The CDC states that patients suffering from severe obesity (BMI ≥40 kg/m2) and chronic kidney disease (CKD) who are undergoing dialysis, are at increased risk for severe illness. In 2018, an estimated 32.5% of Michigan adults were classified as obese (BMI ≥30kg/m2), with an additional 35% classified as overweight (BMI 25 to <30).17 Likewise, more than one million Michigan adults (or 1 in 7) suffer from chronic kidney disease.18 Future studies should investigate associations between disease progression and comorbidities like obesity and CKD, which are more specific to the American population.
Many patients were taking NSAIDs, ACEIs or ARBs. The effects of NSAIDs on clinical outcomes in COVID-19 infections remain unclear, and the World Health Organization (WHO) have retracted their prior recommendation to avoid NSAID use. The Food and Drugs Administration (FDA) reports the absence “of current scientific evidence connecting use of NSAIDs to worsening COVID-19 symptoms”.19,20 The American College of Cardiology/American Heart Association (ACC/AHA) guidelines currently state that there are no experimental or clinical data demonstrating beneficial or adverse outcomes with background use of ACEI, ARBs or other renin-angiotensin aldosterone system (RAAS) antagonists in COVID-19 or among COVID-19 patients with a history of cardiovascular disease treated with such agents. Continuation of RAAS antagonists for those patients who are currently prescribed such agents for indications for which these agents are known to be beneficial, such as heart failure, hypertension, or ischemic heart disease is recommended.21
The current worldwide COVID-19 mortality is 6.9%, with large variations within different countries with US mortality being 3.8%, Spain 10.2%, Italy 12.8% and China 4.0%22,23. Our cohort had a low mortality rate likely because a third of the patients had a mild clinical presentation and no overt comorbidities. Among 44,672 confirmed cases of COVID-19 in China, the fatality rate for patients without reported comorbidities was 0.9%, while the fatality rate for patients with cardiovascular disease, diabetes mellitus, and chronic respiratory disease were 10.5%, 7.3%, and 6.3%, respectively.24
Limitations & strengths:
This study is limited by the retrospective nature of its design. Most of the data was limited to the electronic medical record documentation and adjudication of outcomes via individual chart review was not performed. Outcomes were reported only if the events occurred in our health system. Strengths of this study include a large sample size and thorough manual data collection confirming the disposition of the patients at the time of the COVID-19 assessment and their clinical symptoms upon presentation to ED. Follow up time was sufficient to capture 92.4% of the outcomes. The patient population in this cohort is very diverse and representative of all the racial minorities.