Discussion
This study represents the first case series of sequentially hospitalized laboratory confirmed COVID-19 patients from a regional hospital in Spain.
In comparison with other series of hospitalized patients, our study includes and represents older patients, with a median age of 75 years old (range 28-96) and more than a third over 80 years old. Series from China, United States and Italy included younger patients ranging from 47 to 55 in China1,4,7 and from 61 to 64 in United States and Italy6,12-16. In addition, the median age of a larger retrospective study from Spanish University Hospitals (mostly from Madrid) was 69.4 years old17.
In a similar way to these previous series, our patients had many comorbidities (arterial hypertension, diabetes mellitus and cardiovascular diseases were the most frequent) and a low proportion of smokers, history of chronic respiratory diseases or HIV infection1,4,7,12-19. The clinical and laboratory presentation were also similar to the already described, and, unlike other centres, we have performed few chest CT scans (in part, to avoid transferring patients outside the isolation area) and more LUS. In our opinion, LUS can be very useful in characterizing lung involvement of COVID-19 even when chest radiograph is normal11.
The COVID-19 related signs and symptoms found in our study are similar to those reported in previous studies with the exception of a low proportion (3%) of smell and taste alterations. This is surprising when compared to the high proportion of our healthcare workers affected by COVID-19 who presented these symptoms (53%)8. There is a wide range of these symptoms ranging from 7% in hospitalized patients from Spain to 64% in mildly symptomatic outpatients from Italy20. It is probable that less severe patients tend to express these symptoms more often than more severely ill ones.
We found a high in-hospital mortality in our study (26%). This data is clearly higher than those reported at the start of the pandemic in China (1.4-11%)1,4 and the first communications from the United States (10-21% in New York City and 15.6% in California)13-14. This proportion is also slightly higher than the 20% morality rate more recently reported in the abovementioned studies from Italy and Spain16,17. The old population and high comorbidity of our patients may explain, in part, this high mortality rate. We believe that mortality could have been even higher if more patients had been admitted from long-term care facilities (17% in the present study) were mortality rates are higher than 30%5.
Apart from age and comorbidities we have found other variables associated with the composite outcome (death or ICU admission) including respiratory insufficiency or radiographic abnormalities at presentation, more prominent laboratory abnormalities, and requiring higher oxygen concentrations. In the multivariate analysis only a high comorbidity burden (measured with the PROFUND score) and high C-reactive protein values, remained statistically significant risk factor. It is important to early identify these patients and try to modify their prognosis. We have also found that those patients treated with hydroxychloroquine and azithromycin had a better prognosis, but this finding should be interpreted with caution. Treatment assignation was not randomized, and it was prescribed according to regional protocols, at treating physician discretion and after consent of the patient.
The main strength of this study is that it is prospective (including all consecutively hospitalized patients) and that it offers unpublished information so far, including advanced age patients, from a non-university regional hospital and from Spain. The main limitation of this study is that the data only represent a single centre in a rural region of Spain, so the findings cannot be generalized. More studies from Spain and other European countries are necessary to verify the clinical characteristics, in-hospital mortality rates and prognostic factors of COVID-19.
In conclusion, case-fatality rate of patients hospitalized with COVID-19 in the early days of the Spanish epidemic was high (26%). A high comorbidity burden and high C-reactive protein values were factors related with increased risk of death or ICU admission.