Presenting Characteristics, Comorbidities, and Outcomes Among 5700Patients Hospitalized With COVID-19 in the New York City AreaSafiya Richardson, MD, MPH; Jamie S. Hirsch, MD, MA, MSB; Mangala Narasimhan, DO;James M. Crawford, MD, PhD; Thomas McGinn, MD, MPH; Karina W. Davidson, PhD, MASc;and the Northwell COVID-19 Research Consortium
IMPORTANCE There is limited information describing the presenting characteristics andoutcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19).
OBJECTIVE To describe the clinical characteristics and outcomes of patients with COVID-19hospitalized in a US health care system.
DESIGN, SETTING, AND PARTICIPANTS Case series of patients with COVID-19 admitted to 12hospitals in New York City, Long Island, and Westchester County, New York, within theNorthwell Health system. The study included all sequentially hospitalized patients betweenMarch 1, 2020, and April 4, 2020, inclusive of these dates.
EXPOSURES Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)infection by positive result on polymerase chain reaction testing of a nasopharyngeal sampleamong patients requiring admission.
MAIN OUTCOMES AND MEASURES Clinical outcomes during hospitalization, such as invasivemechanical ventilation, kidney replacement therapy, and death. Demographics, baselinecomorbidities, presenting vital signs, and test results were also collected.
RESULTS A total of 5700 patients were included (median age, 63 years [interquartile range{IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities werehypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage,30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/minute,and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%.Outcomes were assessed for 2634 patients who were discharged or had died at the studyend point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78];33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasivemechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553(21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151,20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained inhospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45patients (2.2%) were readmitted during the study period. The median time to readmissionwas 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remainedhospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the medianfollow-up at time of censoring was 4.5 days (IQR, 2.4-8.1).
CONCLUSIONS AND RELEVANCE This case series provides characteristics and early outcomes ofsequentially hospitalized patients with confirmed COVID-19 in the New York City area.
JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775Published online April 22, 2020. Corrected on April 24, 2020.
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Author Affiliations: Institute ofHealth Innovations and OutcomesResearch, Feinstein Institutes forMedical Research, Northwell Health,Manhasset, New York (Richardson,Hirsch, McGinn, Davidson); Donaldand Barbara Zucker School ofMedicine at Hofstra/Northwell,Northwell Health, Hempstead,New York (Richardson, Hirsch,Narasimhan, Crawford, McGinn,Davidson); Department ofInformation Services, NorthwellHealth, New Hyde Park, New York(Hirsch).
Group Information: The NorthwellCOVID-19 Research Consortiumauthors and investigators appear atthe end of the article.
Corresponding Author: Karina W.Davidson, PhD, Northwell Health,130 E 59th St, Ste 14C, New York, NY10022 ([email protected]).
Research
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T he first confirmed case of coronavirus disease 2019(COVID-19) in the US was reported from WashingtonState on January 31, 2020.1 Soon after, Washington andCalifornia reported outbreaks, and cases in the US have nowexceeded total cases reported in both Italy and China.2 The rateof infections in New York, with its high population density,has exceeded every other state, and, as of April 20, 2020, ithas more than 30% of all of the US cases.3
Limited information has been available to describe thepresenting characteristics and outcomes of US patientsrequiring hospitalization with this illness. In a retrospectivecohort study from China, hospitalized patients were pre-dominantly men with a median age of 56 years; 26% requiredintensive care unit (ICU) care, and there was a 28% mortalityrate.4 However, there are significant differences betweenChina and the US in population demographics,5 smokingrates,6 and prevalence of comorbidities.7
This study describes the demographics, baseline comor-bidities, presenting clinical tests, and outcomes of the first se-quentially hospitalized patients with COVID-19 from an aca-demic health care system in New York.
MethodsThe study was conducted at hospitals in Northwell Health,the largest academic health system in New York, serving ap-proximately 11 million persons in Long Island, WestchesterCounty, and New York City. The Northwell Health institutionalreview board approved this case series as minimal-risk re-search using data collected for routine clinical practice andwaived the requirement for informed consent. All consecutivepatients who were sufficiently medically ill to require hospitaladmission with confirmed severe acute respiratory syndromecoronavirus 2 (SARS-CoV-2) infection by positive result onpolymerase chain reaction testing of a nasopharyngeal samplewere included. Patients were admitted to any of 12 NorthwellHealth acute care hospitals between March 1, 2020, and April4, 2020, inclusive of those dates. Clinical outcomes were moni-tored until April 4, 2020, the final date of follow-up.
Data were collected from the enterprise electronichealth record (Sunrise Clinical Manager; Allscripts) report-ing database, and all analyses were performed using version3.5.2 of the R programming language (R Project for Statisti-cal Computing; R Foundation). Patients were considered tohave confirmed infection if the initial test result was posi-tive or if it was negative but repeat testing was positive.Repeat tests were performed on inpatients during hospital-ization shortly after initial test results were available if therewas a high clinical pretest probability of COVID-19 or if theinitial negative test result had been judged likely to be afalse-negative due to poor sample collection. Transfers fromone in-system hospital to another were merged and consid-ered as a single visit. There were no transfers into or out ofthe system. For patients with a readmission during thestudy period, data from the first admission are presented.
Data collected included patient demographic informa-tion, comorbidities, home medications, triage vitals, initial
laboratory tests, initial electrocardiogram results, diagnosesduring the hospital course, inpatient medications, treatments(including invasive mechanic al ventilation and kidneyreplacement therapy), and outcomes (including length ofstay, discharge, readmission, and mortality). Demographics,baseline comorbidities, and presenting clinical studies wereavailable for all admitted patients. All clinical outcomes arepresented for patients who completed their hospital course atstudy end (discharged alive or dead). Clinical outcomes avail-able for those in hospital at the study end point are pre-sented, including invasive mechanical ventilation, ICU care,kidney replacement therapy, and length of stay in hospital.Outcomes such as discharge disposition and readmissionwere not available for patients in hospital at study endbecause they had not completed their hospital course. Homemedications were reported based on the admission medica-tion reconciliation by the inpatient-accepting physicianbecause this is the most reliable record of home medications.Final reconciliation has been delayed until discharge duringthe current pandemic. Home medications are therefore pre-sented only for patients who have completed their hospitalcourse to ensure accuracy.
Race and ethnicity data were collected by self-report inprespecified fixed categories. These data were included asstudy variables to characterize admitted patients. Initiallaboratory testing was defined as the first test results avail-able, typically within 24 hours of admission. For initial labo-ratory testing and clinical studies for which not all patientshad values, percentages of total patients with completedtests are shown. The Charlson Comorbidity Index predicts10-year survival in patients with multiple comorbidities andwas used as a measure of total comorbidity burden.8 Thelowest score of 0 corresponds to a 98% estimated 10-yearsurvival rate. Increasing age in decades older than age 50years and comorbidities, including congestive heart diseaseand cancer, increase the total score and decrease the esti-mated 10-year survival. A total of 16 comorbidities areincluded. A score of 7 points and above corresponds to a 0%estimated 10-year survival rate. Acute kidney injury wasidentified as an increase in serum creatinine by 0.3 mg/dLor more (≥26.5 μmol/L) within 48 hours or an increase in
Key PointsQuestion What are the characteristics, clinical presentation, andoutcomes of patients hospitalized with coronavirus disease 2019(COVID-19) in the US?
Findings In this case series that included 5700 patientshospitalized with COVID-19 in the New York City area, the mostcommon comorbidities were hypertension, obesity, and diabetes.Among patients who were discharged or died (n = 2634), 14.2%were treated in the intensive care unit, 12.2% received invasivemechanical ventilation, 3.2% were treated with kidneyreplacement therapy, and 21% died.
Meaning This study provides characteristics and earlyoutcomes of patients hospitalized with COVID-19 in theNew York City area.
Clinical Characteristics, Comorbidities, and Outcomes Among Patients With COVID-19 Hospitalized in the NYC Area Original Investigation Research
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serum creatinine to 1.5 times or more baseline within theprior 7 days compared with the preceding 1 year of data inacute care medical records. This was based on the KidneyDisease: Improving Global Outcomes (KDIGO) definition.9
Acute hepatic injury was defined as an elevation in aspar-tate aminotransferase or alanine aminotransferase of morethan 15 times the upper limit of normal.
ResultsA total of 5700 patients were included (median age, 63 years[interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7%female) (Table 1). The median time to obtain polymerasechain reaction testing results was 15.4 hours (IQR, 7.8-24.3).The most common comorbidities were hypertension (3026,56.6%), obesity (1737, 41.7%), and diabetes (1808, 33.8%).The median score on the Charlson Comorbidity Index was 4points (IQR, 2-6), which corresponds to a 53% estimated10-year survival and reflects a significant comorbidity bur-den for these patients. At triage, 1734 patients (30.7%) werefebrile, 986 (17.3%) had a respiratory rate greater than 24breaths/minute, and 1584 (27.8%) received supplementaloxygen (Table 2 and Table 3). The first test for COVID-19 waspositive in 5517 patients (96.8%), while 183 patients (3.2%)had a negative first test and positive repeat test. The rate of
Table 1. Baseline Characteristics of Patients Hospitalized With COVID-19
No. (%)Demographic information
Total No. 5700
Age, median (IQR) [range], y 63 (52-75) [0-107]
Sex
Female 2263 (39.7)
Male 3437 (60.3)
Racea
No. 5441
African American 1230 (22.6)
Asian 473 (8.7)
White 2164 (39.8)
Other/multiracial 1574 (28.9)
Ethnicitya
No. 5341
Hispanic 1230 (23)
Non-Hispanic 4111 (77)
Preferred language non-English 1054 (18.5)
Insurance
Commercial 1885 (33.1)
Medicaid 1210 (21.2)
Medicare 2415 (42.4)
Self-pay 95 (1.7)
Otherb 95 (1.7)
Comorbidities
Total No. 5700
Cancer 320 (6)
Cardiovascular disease
Hypertension 3026 (56.6)
Coronary artery disease 595 (11.1)
Congestive heart failure 371 (6.9)
Chronic respiratory disease
Asthma 479 (9)
Chronic obstructive pulmonary disease 287 (5.4)
Obstructive sleep apnea 154 (2.9)
Immunosuppression
HIV 43 (0.8)
History of solid organ transplant 55 (1)
Kidney disease
Chronicc 268 (5)
End-staged 186 (3.5)
Liver disease
Cirrhosis 19 (0.4)
Chronic
Hepatitis B 8 (0.1)
Hepatitis C 3 (0.1)
Metabolic disease
Obesity (BMI ≥30) 1737 (41.7)
No. 4170
Morbid obesity (BMI ≥35) 791 (19.0)
No. 4170
Diabetese 1808 (33.8)
(continued)
Table 1. Baseline Characteristics of Patients Hospitalized With COVID-19(continued)
No. (%)Never smoker 3009 (84.4)
No. 3567
Comorbiditiesf
None 350 (6.1)
1 359 (6.3)
>1 4991 (88)
Total, median (IQR) 4 (2-8)
Charlson Comorbidity Index score, median (IQR)g 4 (2-6)
Abbreviations: BMI, body mass index (calculated as weight in kilograms dividedby height in meters squared); COVID-19, coronavirus disease 2019;IQR, interquartile range.a Race and ethnicity data were collected by self-report in prespecified fixed
categories.b Other insurance includes military, union, and workers’ compensation.c Assessed based on a diagnosis of chronic kidney disease in medical history by
International Statistical Classification of Diseases and Related Health Problems,Tenth Revision (ICD-10) coding.
d Assessed based on a diagnosis of end-stage kidney disease in medical historyby ICD-10 coding.
e Assessed based on a diagnosis of diabetes mellitus and includesdiet-controlled and non–insulin-dependent diabetes.
f Comorbidities listed here are defined as medical diagnoses included in medicalhistory by ICD-10 coding. These include, but are not limited to, thosepresented in the table.
g Charlson Comorbidity Index predicts the 10-year mortality for a patient basedon age and a number of serious comorbid conditions, such as congestive heartfailure or cancer. Scores are summed to provide a total score to predictmortality. The median score of 4 corresponds to a 53% estimated 10-yearsurvival and reflects a significant comorbidity burden for these patients.
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co-infection with another respiratory virus for those testedwas 2.1% (42/1996). Discharge disposition by 10-year ageintervals of all 5700 study patients is included in Table 4.Length of stay for those who died, were discharged alive,and remained in hospital are presented as well. Among the3066 patients who remained hospitalized at the final study
follow-up date (median age, 65 years [IQR 54-75]), themedian follow-up at time of censoring was 4.5 days (IQR,2.4-8.1). Mortality was 0% (0/20) for male and femalepatients younger than 20 years. Mortality rates were higherfor male compared with female patients at every 10-year ageinterval older than 20 years.
Table 2. Presentation Vitals and Laboratory Results of Patients Hospitalized With COVID-19
Triage vitalsa No. (%) No. Reference rangesTemperature >38 °C 1734 (30.7)
5644Temperature, median (IQR), °C 37.5 (36.9-38.3)
Oxygen saturation
<90% 1162 (20.4)5693
% Median (IQR) 95 (91-97)
Received supplemental oxygen at triage 1584 (27.8) 5693
Respiratory rate >24 breaths/min 986 (17.3) 5695
Heart rate
≥100 beats/min 2457 (43.1)5696
Median (IQR) 97 (85-110)
Initial laboratory measures,median (IQR)a
White blood cell count, ×109/L 7.0 (5.2-9.5) 5680 3.8-10.5
Absolute count, ×109/L
Neutrophil 5.3 (3.7-7.7) 5645 1.8-7.4
Lymphocyte 0.88 (0.6-1.2) 5645 1.0-3.3
Lymphocyte, <1000 ×109/L 3387 (60)
Sodium, mmol/L 136 (133-138) 5645 135-145
Aspartate aminotransferase, U/L 46 (31-71) 5586 10-40
Aspartate aminotransferase >40 U/L 3263 (58.4)
Alanine aminotransferase, U/L 33 (21-55) 5587 10-45
Alanine aminotransferase >60 U/L 2176 (39.0)
Creatine kinase, U/L 171 (84-397) 2527 25-200
Venous lactate, mmol/L 1.5 (1.1-2.1) 2508 0.7-2.0
Troponin above test-specific upper limitof normalb
801 (22.6) 3533
Brain-type natriuretic peptide,pg/mL
385.5 (106-1996.8) 1818 0-99
Procalcitonin, ng/mL 0.2 (0.1-0.6) 4138 0.02-0.10
D-dimer, ng/mL 438 (262-872) 3169 0-229
Ferritin, ng/mL 798 (411-1515) 4344 15-400
C-reactive protein, mg/dL 13.0 (6.4-26.9) 4517 0.0-0.40
Lactate dehydrogenase, U/L 404.0 (300-551.5) 4003 50-242
Admission studiesa
ECG, QTC >500c 260 (6.1) 4250 <400
Respiratory viral panel, positivefor non–COVID-19 respiratory virus
42 (2.1) 1996
Chlamydia pneumoniae 2 (4.8)
Coronavirus (non–COVID-19) 7 (16.7)
Entero/rhinovirus 22 (52.4)
Human metapneumovirus 2 (4.8)
Influenza A 1 (2.4)
Mycoplasma pneumoniae 1 (2.4)
Parainfluenza 3 3 (7.1)
Respiratory syncytial virus 4 (9.5)
Length of stay for patients in hospitalat study end point, median (IQR), d
4.5 (2.4-8.1)
No. 3066
Abbreviations: COVID-19, coronavirusdisease 2019; ECG,electrocardiogram; IQR, interquartilerange; QTC, corrected QT interval.
SI conversion factors: To convertalanine aminotransferase, alkalinephosphatase, aspartateaminotransferase, creatinine kinase,and lactate dehydrogenase to μkat/L,multiply by 0.0167.a Triage vital signs, initial laboratory
measures, and admission studieswere selected to be included herebased on relevance to thecharacterization of patients withCOVID-19.
b Troponin I; troponin T;and troponin T, high sensitivity areused at about equal frequencyacross these institutions. Forsimplicity, we present the numberand percentage of test results thatwere above the upper limit ofnormal for the individual referencesranges for these 3 tests.
c QTC resulted from the automatedECG reading.
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Outcomes for Patients Who Were Discharged or DiedAmong the 2634 patients who were discharged or had diedat the study end point, during hospitalization, 373 (14.2%)were treated in the ICU, 320 (12.2%) received invasivemechanical ventilation, 81 (3.2%) were treated with kidneyreplacement therapy, and 553 (21%) died (Table 5). As ofApril 4, 2020, for patients requiring mechanical ventilation(n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282(24.5%) died, and 831 (72.2%) remained in hospital. Mortal-ity rates for those who received mechanical ventilation inthe 18-to-65 and older-than-65 age groups were 76.4% and97.2%, respectively. Mortality rates for those in the 18-to-65and older-than-65 age groups who did not receive mechani-cal ventilation were 1.98% and 26.6%, respectively. Therewere no deaths in the younger-than-18 age group. The over-all length of stay was 4.1 days (IQR, 2.3-6.8). The medianpostdischarge follow-up time was 4.4 days (IQR, 2.2-9.3).
A total of 45 patients (2.2%) were readmitted during thestudy period. The median time to readmission was 3 days(IQR, 1.0-4.5). Of the patients who were discharged or haddied at the study end point, 436 (16.6%) were younger thanage 50 with a score of 0 on the Charlson Comorbidity Index,of whom 9 died.
Outcomes by Age and Risk FactorsFor both patients discharged alive and those who died, thepercentage of patients who were treated in the ICU orreceived invasive mechanical ventilation was increased forthe 18-to-65 age group compared with the older-than-65years age group (Table 5). For patients discharged alive, thelowest absolute lymphocyte count during hospital coursewas lower for progressively older age groups. For patientsdischarged alive, the readmission rates and the percentage ofpatients discharged to a facility (such as a nursing home or
Table 3. Hospital Characteristics and Admission Rates
Hospitala
No. (%)
Study admissions(N = 5700)
Acute beds(March occupancy),meanb
Annual emergencydepartment visits(% admitted)
North Shore University Hospital 1073 (18.8) 637 (92) 51 000 (34)
Long Island Jewish Medical Center 1151 (20.2) 517 (91) 66 000 (28)
Staten Island University Hospital 674 (11.9) 466 (85) 93 000 (25)
Lenox Hill Hospital 558 (9.8) 324 (75) 40 000 (29)
Southside Hospital 445 (7.8) 270 (86) 59 000 (18)
Huntington Hospital 359 (6.3) 231 (81) 40 000 (22)
Long Island Jewish Forest Hills 608 (10.7) 187 (86) 42 000 (21)
Long Island Jewish Valley Stream 355 (6.2) 180 (75) 31 000 (23)
Plainview Hospital 231 (4.1) 156 (70) 24 000 (29)
Cohen Children’s Medical Center 42 (0.7) 111 (78) 48 000 (14)
Glen Cove Hospital, nonteaching 117 (2.1) 66 (78) 15 000 (20)
Syosset Hospital 87 (1.5) 55 (70) 12 000 (21)
a Teaching hospital unless otherwisenoted.
b More than 1200 acute beds wereadded across the system during themonth of March 2020.
Table 4. Discharge Disposition by 10-Year Age Intervals of Patients Hospitalized With COVID-19
Patients discharged aliveor dead at study end point
Patients in hospitalat study end point
Died, No./No. (%)Length of stayamong thosewho died,median (IQR), da
Discharged alive, No./No. (%)Length of stayamong thosedischarged alive,median (IQR), da No./No. (%)
Length of stay,median (IQR), daMale Female Male Female
Age intervals, y
0-9 0/13 0/13 NA 13/13 (100) 13/13 (100) 2.0 (1.7-2.7) 7/33 (21.2) 4.3 (3.1-12.5)
10-19 0/1 0/7 NA 1/1 (100) 7/7 (100) 1.8 (1.0-3.1) 9/17 (52.9) 3.3 (2.8-4.3)
20-29 3/42 (7.1) 1/55 (1.8) 4.0 (0.8-7.4) 39/42 (92.9) 54/55 (98.2) 2.5 (1.8-4.0) 52/149 (34.9) 3.2 (1.9-6.4)
30-39 6/130 (4.6) 2/81 (2.5) 2.8 (2.4-3.6) 124/130 (95.4) 79/81 (97.5) 3.7 (2.0-5.8) 142/353 (40.2) 5.1 (2.5-9.0)
40-49 19/233 (8.2) 3/119 (2.5) 5.6 (3.0-8.4) 214/233 (91.8) 116/119 (97.5) 3.9 (2.3-6.1) 319/671 (47.5) 4.9 (2.9-8.2)
50-59 40/327 (12.2) 13/188 (6.9) 5.9 (3.1-9.5) 287/327 (87.8) 175/188 (93.1) 3.8 (2.5-6.7) 594/1109 (53.6) 4.9 (2.8-8.0)
60-69 56/300 (18.7) 28/233 (12.0) 5.7 (2.6-8.2) 244/300 (81.3) 205/233 (88.0) 4.3 (2.5-6.8) 771/1304 (59.1) 5.0 (2.4-8.2)
70-79 91/254 (35.8) 54/197 (27.4) 5.0 (2.7-7.8) 163/254 (64.2) 143/197 (72.6) 4.6 (2.8-7.8) 697/1148 (60.7) 4.5 (2.3-8.2)
80-89 94/155 (60.6) 76/158 (48.1) 3.9 (2.1-6.5) 61/155 (39.4) 82/158 (51.9) 4.4 (2.7-7.7) 369/682 (54.1) 4.1 (2.1-7.4)
≥90 28/44 (63.6) 39/84 (46.4) 3.0 (0.7-5.5) 16/44 (36.4) 45/84 (53.6) 4.8 (2.8-8.4) 106/234 (45.3) 3.2 (1.5-6.4)
Abbreviations: COVID-19, coronavirus disease 2019; IQR, interquartile range;NA, not applicable.a Length of stay begins with admission time and ends with discharge time, time
at death, or midnight on the last day of data collection for the study. It doesnot include time in the emergency department.
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rehabilitation), as opposed to home, increased for progres-sively older age groups.
Of the patients who died, those with diabetes were morelikely to have received invasive mechanical ventilation orcare in the ICU compared with those who did not have diabe-tes (eTable 1 in the Supplement). Of the patients who died,those with hypertension were less likely to have receivedinvasive mechanical ventilation or care in the ICU comparedwith those without hypertension. The percentage of patients
who developed acute kidney injury was increased in the sub-groups with diabetes compared with subgroups withoutthose conditions.
Angiotensin-Converting Enzyme Inhibitor and Angiotensin IIReceptor Blocker UseHome medication reconciliation information was available for2411 (92%) of the 2634 patients who were discharged or who diedby the study end. Of these 2411 patients, 189 (7.8%) were taking
Table 5. Clinical Measures and Outcomes for Patients Discharged Alive, Dead, and In Hospital at Study End Point by Age
Clinical measure
Total discharged aliveand dead patients(N = 2634)
Discharged alive Died In hospital<18 y(n = 32)
18-65 y(n = 1373)
>65 y(n = 676)
<18 y(n = 0)
18-65 y(n = 134)
>65 y(n = 419)
<18(n = 14)
18-65(n = 1565)
>65(n = 1487)
Invasivemechanicalventilationa
320 (12.2) 0 33 (2.4) 5 (0.7) NA 107 (79.9) 175 (41.8) 4 (28.6) 449 (28.7) 378 (25.4)
ICU care 373 (14.2) 2 (6.3) 62 (4.5) 18 (2.7) NA 109 (81.3) 182 (43.4) 5 (35.7) 490 (31.3) 413 (27.8)
Absolutelymphocytecount at nadir,median (IQR),×109/L(reference range,1.0-3.3)
0.8 (0.5-1.14) 2.3(1.2-5.0)
0.9(0.7-1.2)
0.8(0.5-1.1)
NA 0.5(0.3-0.8)
0.5(0.3-0.8)
2.0(1.0-3.5)
0.7(0.5-1.0)
0.6(0.4-0.9)
No. 2626 32 1371 675 134 417 3 1564 1486
Acute kidneyinjuryb
523 (22.2) 1 (11.1) 93 (7.5) 82 (13.1) NA 98 (83.8) 249 (68.4) 2 (14.3) 388 (25.5) 457 (34.5)
No. 2351 8 1237 624 117 364 8 1400 1326
Kidneyreplacementtherapy
81 (3.2) 0 2 (0.1) 1 (0.2) NA 43 (35.0) 35 (8.8) 0 82 (5.4) 62 (4.4)
Acute hepaticinjuryc
56 (2.1) 0 3 (0.2) 0 NA 25 (18.7) 28 (6.7) 0 21 (1.3) 12 (0.8)
No. 1371 675 134 417 3 1564 1486
Outcomes
Length of stay,median (IQR), dd
4.1 (2.3-6.8) 2.0(1.7-2.8)
3.8(2.3-6.2)
4.5(2.7-7.2)
NA 5.5(2.9-8.4)
4.4(2.1-7.1)
4.0(2.4-6.2)
4.8(2.5-8.1)
4.4(2.3-8.0)
Discharged alive 3.9 (2.4-6.7)
Died 4.8 (2.3-7.4)
Died 553 (21) NA NA NA NA NA NA NA NA N/A
Died, of those whodid not receivemechanicalventilation
271/2314 (11.7) NA NA NA NA NA NA NA NA
Died, of those whodid receivemechanicalventilation
282/320 (88.1)
Readmittede 45 (2.2) 1 (3.1) 22 (1.6) 22 (3.3) NA NA NA NA NA NA
Discharge dispositionof 2081 patientsdischarged alive
No. 2081
Home 1959 (94.1) 32 (100) 1345 (98.0) 582 (86.1) NA NA NA NA NA NA
Facilities(ie, nursinghome, rehab)
122 (5.9) 0 28 (2.0) 94 (13.9) NA NA NA NA NA NA
Abbreviations: ICU, intensive care unit; IQR, interquartile range; NA, notapplicable.a Policy in the system has been not to treat patients with COVID-19 with bilevel
positive airway pressure and continuous positive airway pressure out ofconcern for aerosolizing virus particles and therefore that information is notreported here.
b Acute kidney injury was identified as an increase in serum creatinineby �0.3 mg/dL (�26.5 mol/L) within 48 hours or an increase in serumcreatinine to �1.5 times baseline within the prior 7 days compared with thepreceding 1 year of data in acute care medical records. Acute kidney injury is
calculated only for patients with record of baseline kidney function dataavailable and without a diagnosis of end-stage kidney disease.
c Acute hepatic injury was defined as an elevation in aspartate aminotransferaseor alanine aminotransferase of >15 times the upper limit of normal.
d Length of stay begins with admission time and ends with discharge time ortime of death. It does not include time in the emergency department.
e Data are presented here for readmission during the study period, March 1 toApril 4, 2020.
Clinical Characteristics, Comorbidities, and Outcomes Among Patients With COVID-19 Hospitalized in the NYC Area Original Investigation Research
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an angiotensin-converting enzyme inhibitor (ACEi) at home and267 (11.1%) were taking an angiotensin II receptor blocker (ARB)at home. The median number of total home medications was 3(IQR, 0-7). Outcomes for subgroups of patients with hypertensionby use of ACEi or ARB home medication are shown in eTable 2 inthe Supplement. Numbers provided for total patients taking ACEior ARB therapy in eTable 2 in the Supplement are provided onlyfor patients who also had a diagnosis of hypertension.
Of the patients taking an ACEi at home, 91 (48.1%) contin-ued taking an ACEi while in the hospital and the remainder dis-continued this type of medication during their hospital visit. Ofthe patients taking an ARB at home, 136 (50.1%) continued tak-ing an ARB while in the hospital and the remainder discontin-ued taking this type of medication during their hospital visit. Ofpatients who were not prescribed an ACEi or ARB at home, 49started treatment with an ACEi and 58 started treatment withan ARB during their hospitalization. Mortality rates for patientswith hypertension not taking an ACEi or ARB, taking an ACEi,and taking an ARB were 26.7%, 32.7%, and 30.6%, respectively.
DiscussionTo our knowledge, this study represents the first large case se-ries of sequentially hospitalized patients with confirmedCOVID-19 in the US. Older persons, men, and those with pre-existing hypertension and/or diabetes were highly prevalentin this case series and the pattern was similar to data reportedfrom China.4 However, mortality rates in this case series weresignificantly lower, possibly due to differences in thresholdsfor hospitalization. This study reported mortality rates only forpatients with definite outcomes (discharge or death), and lon-ger-term study may find different mortality rates as differentsegments of the population are infected. The findings of highmortality rates among ventilated patients are similar to smallercase series reports of critically ill patients in the US.10
ACEi and ARB medications can significantly increase mRNAexpression of cardiac angiotensin-converting enzyme 2 (ACE2),11
leading to speculation about the possible adverse, protective,or biphasic effects of treatment with these medications.12 Thisis an important concern because these medications are the mostprevalent antihypertensive medications among all drugclasses.13 However, this case series design cannot address thecomplexity of this question, and the results are unadjusted forknown confounders, including age, sex, race, ethnicity, socio-economic status indicators, and comorbidities such as diabe-tes, chronic kidney disease, and heart failure.
Mortality rates are calculated only for patients who weredischarged alive or died by the study end point. This biases ourrates toward including more patients who died early in theirhospital course. Most patients in this study were still in hos-pital at the study end point (3066, 53.8%). We expect that asthese patients complete their hospital course, reported mor-tality rates will decline.
LimitationsThis study has several limitations. First, the study popula-tion only included patients within the New York metropoli-tan area. Second, the data were collected from the electronichealth record database. This precluded the level of detail pos-sible with a manual medical record review. Third, the medianpostdischarge follow-up time was relatively brief at 4.4 days(IQR, 2.2-9.3). Fourth, subgroup descriptive statistics were un-adjusted for potential confounders. Fifth, clinical outcome datawere available for only 46.2% of admitted patients. The ab-sence of data on patients who remained hospitalized at the fi-nal study date may have biased the findings, including the highmortality rate of patients who received mechanical ventila-tion older than age 65 years.
ConclusionsThis case series provides characteristics and early outcomesof sequentially hospitalized patients with confirmed COVID-19in the New York City area.
ARTICLE INFORMATION
Accepted for Publication: April 16, 2020.
Published Online: April 22, 2020.doi:10.1001/jama.2020.6775
Correction: This article was corrected on April 24,2020, to clarify the mortality rate of ventilatedpatients, correct the COVID-19 positive/negativetest results, and correct the data for concurrententero/rhinovirus infection in Table 2.
The Northwell COVID-19 Research ConsortiumAuthors: Douglas P. Barnaby, MD, MSc; Lance B.Becker, MD; John D. Chelico, MD, MA; Stuart L.Cohen, MD; Jennifer Cookingham, MHA; KevinCoppa, BS; Michael A. Diefenbach, PhD; Andrew J.Dominello, BA; Joan Duer-Hefele, RN, MA;Louise Falzon, BA, PGDipInf; Jordan Gitlin, MD;Negin Hajizadeh, MD, MPH; Tiffany G. Harvin, MBA;David A. Hirschwerk, MD; Eun Ji Kim, MD, MS, MS;Zachary M. Kozel, MD; Lyndonna M. Marrast, MD,MPH; Jazmin N. Mogavero, MA; Gabrielle A.Osorio, MPH; Michael Qiu, MD, PhD; Theodoros P.Zanos, PhD.
Affiliations of The Northwell COVID-19 ResearchConsortium Authors: Institute of HealthInnovations and Outcomes Research, FeinsteinInstitutes for Medical Research, Northwell Health,Manhasset, New York (Barnaby, Chelico,Cohen, Cookingham, Diefenbach, Dominello,Duer-Hefele, Falzon, Hajizadeh, Harvin, Kim,Marrast, Mogavero, Osorio); Donald and BarbaraZucker School of Medicine at Hofstra/Northwell,Northwell Health, Hempstead, New York (Barnaby,Becker, Chelico, Cohen, Gitlin, Hajizadeh,Hirschwerk, Kim, Kozel, Marrast); Department ofInformation Services, Northwell Health, New HydePark, New York (Coppa, Qiu); Institute ofBioelectronic Medicine, Feinstein Institutes forMedical Research, Northwell Health, Manhasset,New York (Zanos).
Author Contributions: Drs Richardson andDavidson had full access to all of the data in thestudy and take responsibility for the integrity of thedata and the accuracy of the data analysis.Concept and design: Richardson, Hirsch,Narasimhan, Crawford, McGinn, Davidson, Barnaby,
Chelico, Cohen, Cookingham, Coppa, Diefenbach,Duer-Hefele, Dominello, Falzon, Gitlin, Hirschwerk,Kozel, Marrast, Mogavero.Acquisition, analysis, or interpretation of data:Richardson, Hirsch, Narasimhan, Crawford,Davidson, Barnaby, Becker, Chelico, Cohen, Coppa,Diefenbach, Duer-Hefele, Hajizadeh, Harvin,Hirschwerk, Kim, Kozel, Marrast, Osorio, Qiu, Zanos.Drafting of the manuscript: Richardson, McGinn,Davidson, Cookingham, Falzon, Harvin,Mogavero, Qiu.Critical revision of the manuscript for importantintellectual content: Richardson, Hirsch,Narasimhan, Crawford, McGinn, Barnaby, Becker,Chelico, Cohen, Coppa, Diefenbach, Duer-Hefele,Dominello, Gitlin, Hajizadeh, Hirschwerk, Kim,Kozel, Marrast, Osorio, Zanos.Statistical analysis: Hirsch, Chelico, Zanos.Obtained funding: Richardson.Administrative, technical, or material support:Richardson, Narasimhan, Crawford, Davidson,Chelico, Cookingham, Diefenbach, Dominello,Harvin, Mogavero, Osorio, Zanos.
Research Original Investigation Clinical Characteristics, Comorbidities, and Outcomes Among Patients With COVID-19 Hospitalized in the NYC Area
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Supervision: Narasimhan, McGinn, Becker, Chelico,Zanos.
Conflict of Interest Disclosures: Dr Crawfordreported receiving grants from Regeneron outsidethe submitted work. Dr Becker reported serving onthe scientific advisory board for Nihon Kohden andreceiving grants from the National Institutes ofHealth, United Therapeutics, Philips, Zoll, andPatient-Centered Outcomes Research Instituteoutside the submitted work. Dr Cohen reportedreceiving personal fees from Infervision outside thesubmitted work. No other disclosures werereported.
Funding/Support: This work was supported bygrants R24AG064191 from the National Institute onAging of the National Institutes of Health;R01LM012836 from the National Library ofMedicine of the National Institutes of Health; andK23HL145114 from the National Heart, Lung, andBlood Institute.
Role of the Funder/Sponsor: The funders had norole in the design and conduct of the study;collection, management, analysis, andinterpretation of the data; preparation, review, orapproval of the manuscript; and decision to submitthe manuscript for publication.
The Northwell COVID-19 Research ConsortiumInvestigators: Douglas P. Barnaby, MD, MSc, LanceB. Becker, MD, John D. Chelico, MD, MA, Stuart L.Cohen, MD, Jennifer Cookingham, MHA, KevinCoppa, BS, Michael A. Diefenbach, PhD, Andrew J.Dominello, BA, Joan Duer-Hefele, RN, MA, LouiseFalzon, BA, Jordan Gitlin, MD, Negin Hajizadeh, MD,MPH, Tiffany G. Harvin, MBA, David A. Hirschwerk,MD, Eun Ji Kim, MD, MS, MS, Zachary M. Kozel, MD,Lyndonna M. Marrast, MD, MPH, Jazmin N.Mogavero, MA, Gabrielle A. Osorio, MPH, MichaelQiu, MD, PhD, and Theodoros P. Zanos, PhD.
Disclaimer: The views expressed in this article arethose of the authors and do not represent the views
of the National Institutes of Health, the USDepartment of Health and Human Services, or anyother government entity. Karina W. Davidson is amember of the US Preventive Services Task Force(USPSTF). This article does not represent the viewsand policies of the USPSTF.
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