Differences and Similarities Among COVID-19 Patients Treated in Seven ICUs in Three Countries Within One Region: An Observational Cohort Study*

Abstract

OBJECTIVES: To investigate healthcare system–driven variation in general characteristics, interventions, and outcomes in coronavirus disease 2019 (COVID-19) patients admitted to the ICU within one Western European region across three countries. DESIGN: Multicenter observational cohort study. SETTING: Seven ICUs in the Euregio Meuse-Rhine, one region across Belgium, The Netherlands, and Germany. PATIENTS: Consecutive COVID-19 patients supported in the ICU during the first pandemic wave. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline demographic and clinical characteristics, laboratory values, and outcome data were retrieved after ethical approval and data-sharing agreements. Descriptive statistics were performed to investigate country-related practice variation. From March 2, 2020, to August 12, 2020, 551 patients were admitted. Mean age was 65.4 ± 11.2 years, and 29% were female. At admission, Acute Physiology and Chronic Health Evaluation II scores were 15.0 ± 5.5, 16.8 ± 5.5, and 15.8 ± 5.3 ( p = 0.002), and Sequential Organ Failure Assessment scores were 4.4 ± 2.7, 7.4 ± 2.2, and 7.7 ± 3.2 ( p < 0.001) in the Belgian, Dutch, and German parts of Euregio, respectively. The ICU mortality rate was 22%, 42%, and 44%, respectively ( p < 0.001). Large differences were observed in the frequency of organ support, antimicrobial/inflammatory therapy application, and ICU capacity. Mixed-multivariable logistic regression analyses showed that differences in ICU mortality were independent of age, sex, disease severity, comorbidities, support strategies, therapies, and complications. CONCLUSIONS: COVID-19 patients admitted to ICUs within one region, the Euregio Meuse-Rhine, differed significantly in general characteristics, applied interventions, and outcomes despite presumed genetic and socioeconomic background, admission diagnosis, access to international literature, and data collection are similar. Variances in healthcare systems’ organization, particularly ICU capacity and admission criteria, combined with a rapidly spreading pandemic might be important drivers for the observed differences. Heterogeneity between patient groups but also healthcare systems should be presumed to interfere with outcomes in coronavirus disease 2019.

ACE2 and Innate Immunity in the Regulation of SARS-CoV-2-Induced Acute Lung Injury: A Review

“…Currently, there is no specific drug or vaccine for COVID-19. According to statistics, the mortality rate of severe COVID-19 patients is as high as 22–44% [ 72 , 167 ]. There is an urgent need for more effective treatments in the clinic.…”

Influence of Geopolitics on Severity and Outcome in COVID-19*

“…Race and ethnicity, not provided neither, seem only affecting outcome when access to hospital care is impaired. It is likely that migrants (e.g., from Turkey or the middle East) were infected by COVID-19 as well as the traditional population from this part of Europe, and therefore, the people in the study by Mesotten et al ( 9 ) may represent less a commonality in race, ethnicity, or genetic background per se than a shared socioeconomic background. The German hospital had more patients on extracorporeal membrane oxygenation support.…”

“…Geopolitics and consequential impact on healthcare can have a profound influence on outcomes from illness, particularly in critically ill patients with COVID-19. What can we learn from the findings of the study by Mesotten et al ( 9 )? Aside well-established risk factors such as age, sex, or obesity, the burden of viral load is a major contributor of severity and risk of intubation and is associated with social behaviors ( 11 ).…”

“…CoDaP is a project aimed at developing cross-border consensus treatment guidelines, establishing a COVID-19 data platform, anticipate new waves, and building an efficient and secure information technology infrastructure. The specific goal of the present study by Mesotten et al ( 9 ) was to evaluate practice variation within the Euroregion. The authors’ hypothesis was that variable healthcare system responses to a pandemic drive variability in patient characteristics and disease severity, support strategies, therapies, and complications and impact outcome within a cohort of COVID-19 patients admitted to ICUs in a well-defined region of Western Europe.…”

“…In this issue of Critical Care Medicine , Mesotten et al ( 9 ) report on a cohort of patients with COVID-19 as part of the Corona Data driven interventions & data Platform (CoDaP) program, supported by Interreg Euregio Meuse-Rhine with funding from the European Regional Development Fund ( 10 ). CoDaP is a project aimed at developing cross-border consensus treatment guidelines, establishing a COVID-19 data platform, anticipate new waves, and building an efficient and secure information technology infrastructure.…”