The COVID-19 pandemic has implied a significant burden for healthcare systems. The rising number of cases has increased the resource use, leading to drug shortages and an insufficient number of beds in hospitals . To expand the capacity of the SNHS, some temporary field hospitals were opened, such as the pavilions of the city fair in Madrid . Furthermore, due to the lack of resources, only patients with pneumonia who were in serious condition were hospitalized during the peak of the pandemic. Most COVID-19 patients were sent to nearby converted hotels or their homes to be treated by general practitioners [4, 18].
Our results showed that the maximum number of hospitalized patients with this infection was reached on 5th April, when 32,264 beds were occupied in general hospital wards, while 7,088 ICUs beds were occupied on 17th April. In line with our research, the Institute for Health Metrics and Evaluation (IHME) estimated that the maximum number of occupied beds in general wards was 46,081 on 31th March, and 6,430 beds in ICUs on 4th April. However, both studies differ in their methodology, as we estimated the healthcare resource use according to official records and observational studies carried out in Spain, while the IHME developed a microsimulation model based on death reports .
According to our research, the capacity of the ICUs almost doubled during the first wave, as the bed occupancy rate reached 198.77%. This dramatic situation prompted the development of a contingency plan by the Spanish Society of Critical, Intensive and Coronary Medicine Units (SEMICYUC) and other intensive medicine organizations. The new programme was based on increasing the number of ICU beds and other healthcare resources, to avoid the collapse of the SNHS in the following waves and future pandemics . In consonance with these recommendations, Lacasa and colleagues estimated an algorithm to provide optimal rerouting strategies to ICUs patients. Their approach was validated using real-life data from Spain; they concluded that 600 beds could have been available if using local sharing and over 1,300 beds with countrywide sharing. This strategy would improve the management of COVID-19, particularly for patients who would not otherwise have access to ICUs. However, their approach had some limitations, as they considered the transportation of unstable patients in mobile ICUs, and an unlimited number of ambulances and human resources . Besides, the mortality rate in hospitalized patients on general wards was 20.61% , which is in line with a previous study, that reported a mortality rate of 21.1% in hospitalized patients with COVID-19 .
The efficacy of remdesivir in the management of COVID-19 was demonstrated in several studies . Olender and colleagues analysed its efficacy in a non-randomized cohort study, using a propensity score model, and an inverse probability of treatment weighting method. The participants were hospitalized patients with COVID-19, pulmonary infiltrates, and either had oxygen saturation of ≤ 94% on room air or were receiving supplemental oxygen. Their results showed that 74.40% of patients in the remdesivir group versus 59.00% in the standard of care group achieved the primary recovery endpoint at day 14 (adjusted odds ratio: 2.03 [95% CI: 1.34–3.08], p < 0.001). They also observed a 62% lower adjusted odds of all-cause death . In addition, the double-blind, randomized, and placebo-controlled ACTT-1 trial showed that remdesivir improves the time to recovery and clinical status of hospitalized patients with COVID-19 and pneumonia, who require supplemental oxygen , resulting in a reduction in the length of hospital stays and the number of ICU admissions. Despite the ACTT-1 trial did not reach a statistically significant difference in mortality in the overall study population, a post hoc analysis showed that remdesivir significantly reduced the mortality in hospitalized patients with COVID-19 and supplemental oxygen.
Our results showed that remdesivir would have made available up to 7,880 beds in general wards and 2,000 ICU beds for other patients at the peak of the occupancy rates, respectively. Therefore, this new drug would have relieved the pressure on hospitals and the SNHS, due to the pandemic. Furthermore, remdesivir would have implied a 27.51% reduction (95% CI: 14.25% − 34.07%) in deaths due to COVID-19 during the first wave in Spain. It should be noted that a multi-country, open-label randomized trial developed by the WHO showed that remdesivir was not effective in reducing the mortality rate in hospitalized patients with COVID-19 (RR = 0.95 [95% CI: 0.81–1.11], p = 0.50) . Although this conclusion differs from previous evidence, it should be noted that our results refer to those patients who require low-flow oxygen therapy (a National Early Warning Score [NEWS] of 5) , according to the pharmacological protocol used in the SNHS . In addition, the SOLIDARITY trial compared the efficacy of remdesivir in patients with or without mechanical ventilation, regardless of the oxygen delivery system (e.g. low-flow or high-flow devices) .
Our study has some limitations that need to be addressed. First, due to the lack of information about the clinical status of COVID-19 patients, we assumed that 76.1% of hospitalized patients with pneumonia required supplemental oxygen, according to the US records . Nevertheless, a group of experts agreed that this percentage was similar to the clinical practice in Spain. Second, we considered that hospitalized patients who require mechanical ventilation, high-flow oxygen devices, or ECMO are assisted in the ICUs in Spain. Although this practice is widely spread, the management of COVID-19 patients may differ in some Spanish regions. Third, since there are no real-life studies about the efficacy of remdesivir in our country, we assumed the results of the ACTT-1 trial. Fourth, although we considered official sources, our results may be biased due to notification delays and the overwhelmed healthcare system. Fifth, given that the reduction of mortality rates by age group in patients receiving remdesivir was not estimated in the ACTT-1 trial, we estimated the number of prevented deaths by age group using the reduction in the mortality rate for the whole population of the trial. Sixth, since the potential impact on mortality due to the controversial use of other drugs, such as IL6 inhibitors, is unknown, it has not been considered in our study.
Despite of these limitations, the main contributions of our study are: 1) the assessment of the healthcare resources used during the first wave of the pandemic (in terms of occupied beds in general wards and ICUs) in Spain and 2) the potential number of beds available in general wards and ICUs, if remdesivir would have been used for the treatment of COVID-19. Our results showed that this new drug would have avoided almost half of the ICU admissions, so it would have reduced the pressure on the public system, providing a more efficient use of resources. Consequently, in the following waves of the pandemic, although the preventive measurements have reduced the burden of COVID-19 for the SNHS, as well as the death toll , remdesivir will reduce even more the use of healthcare resources, while avoiding preventable deaths.