Has the management of patients with COVID-19 improved?
Text updated on 2020-11-16
Yes, between March 2020 and June 2020, the care of people with COVID-19 in hospitals has improved a lot.
In hospitals in several countries (Belgium, United States, France, Italy, United Kingdom, and Switzerland), it has been observed that the proportion of patients hospitalized for COVID-19 who died (the in-hospital mortality rate of COVID-19 patients) decreased between March 2020 and June 2020.
There are several reasons for this good news:
- With experience, caregivers have become more competent in treating patients with COVID-19. For example, corticosteroid treatment reduces mortality by 35% in patients with severe COVID-19 that previously required invasive mechanical ventilation. The use of non-invasive ventilation techniques (high flow nasal cannula) reduced the rate of patient intubation.
- Because hospitals were less overcrowded in June 2020 than in March 2020, they may have admitted patients whose illness was less severe than those they initially accepted.
- The younger patients are, the less likely they are to die from COVID-19. See the question What are the factors that increase the risk of dying from COVID-19 ?. One can imagine that the patients admitted to the hospital in June were younger compared to those in March.
- Among patients with COVID-19 In late March and early April, a significant proportion had contracted the infection in hospital. These patients, because they were in hospital, may have been more likely to be ill and vulnerable than others and therefore more likely to die from COVID-19.
In Milan, the hospital mortality rate fell from 24% in March 2020 to 2% in May 2020. And the percentage of inpatients who had to be admitted to intensive care units has also fallen.Ciceri, F., Ruggeri, A., Lembo, R., Puglisi, R., Landoni, G., Zangrillo, A., & COVID-BioB Study Group. (2020). Decreased in-hospital mortality in patients with COVID-19 pneumonia. Pathogens and Global Health, 1-2.
In the United Kingdom, the hospital mortality rate fell from 6% in April 2020 to 1.5% in June 2020.June 2020 Report of the Centre for Evidence-Based Medicine, UK.
A study of the 16,749 people with COVID-19 and admitted to hospital in the United Kingdom between February and April 2020 calculated an in-hospital mortality rate of 33%.Docherty, A. B., Harrison, E. M., Green, C. A., Hardwick, H. E., Pius, R., Norman, L., ... & Merson, L. (2020). Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol. medRxiv.
The analysis of 5,700 patients hospitalized for COVID-19 in the New York area between March 2020 and early April 2020 revealed a 21% hospital mortality rate.Richardson, S., Hirsch, J. S., Narasimhan, M., Crawford, J. M., McGinn, T., Davidson, K. W., ... - Cookingham, J. (2020). Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 In the New York City area. Jama.
RECOVERY clinical trial conducted in the United Kingdom in 6,324 patients with COVID-19. Clinical follow-up of 2,104 patients who were treated with corticosteroids for 10 days compared to 4,321 patients who received conventional therapeutic management. Treatment with corticosteroids reduces mortality by 35% in patients with severe COVID-19 that required invasive mechanical ventilation.Singh, A. K., Majumdar, S., Singh, R., & Misra, A. (2020). Role of corticosteroid in the management of COVID-19. A systemic review and a Clinician's perspective. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(5), 971-978.
In this prospective meta-analysis of 7 randomized trials including 1,703 patients of whom 647 died, all-cause mortality at 28 days was lower in patients who received corticosteroids than in those who received usual care or a placebo.Sterne, J. A., Murthy, S., Diaz, J. V., Slutsky, A. S., Villar, J., Angus, D. C., ... & Dequin, P. F. (2020). Association between Administration of Systemic Corticosteroids and Mortality among critically ill patients with COVID-19a meta-analysis. Jama.
This study in patients with COVID-19 who suffer from severe respiratory symptoms shows that ventilation through high-flow nasal cannulas can reduce the rate of intubation, which is an invasive mechanical ventilation technique for the patient.Demoule, A., Vieillard Baron, A., Darmon, M., Beurton, A., Géri, G., Voiriot, G., ... & Dres, M. (2020). High Flow Nasal Canula in Critically Ill Severe COVID-19 Patients. American journal of respiratory and critical care medicine.
This Nature article of November 11, 2020 takes stock of improvements in COVID-19 patient management in the hospital: hard-won experience, less use of ventilators, better understanding of how to use steroids, discontinuation of unproven drugs and procedures, return to standard treatments.Ledford, H. (2020) Why do COVID death rates seem to be falling? Nature.
Report on 108 English intensive care units between March and June 2020.Denis, J.M., McGovern, A.P., Vollmer, S.J., Mateen, B.A. (2020) Improving Survival of Critical Care Patients With Coronavirus Disease 2019 in England. A National Cohort Study, March to June 2020.
A multicenter cohort study on hospitals in France, Belgium, and Switzerland followed more than 4,000 patients admitted to intensive care units between the end of February and early May 2020. Mortality (estimated at 90 days) of ICU patients fell steadily from 42 to 25% during this period (Table S5), with an average case-fatality rate of 31%.Armstrong, R. A., Kane, A. D., & Cook, T. M. (2020). Outcomes from intensive care in patients with COVID-19: a systematic review and meta-analysis of observational studies. Anaesthesia, 75(10), 1340-1349.