Prior diagnoses and medications as risk factors for COVID-19 in a Los Angeles Health System

Abstract

<jats:p>With the continuing coronavirus disease 2019 (COVID-19) pandemic coupled with phased reopening, it is critical to identify risk factors associated with susceptibility and severity of disease in a diverse population to help shape government policies, guide clinical decision making, and prioritize future COVID-19 research. In this retrospective case-control study, we used de-identified electronic health records (EHR) from the University of California Los Angeles (UCLA) Health System between March 9th, 2020 and June 14th, 2020 to identify risk factors for COVID-19 susceptibility (severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) PCR test positive), inpatient admission, and severe outcomes (treatment in an intensive care unit or intubation). Of the 26,602 individuals tested by PCR for SARS-CoV-2, 992 were COVID-19 positive (3.7% of Tested), 220 were admitted in the hospital (22% of COVID-19 positive), and 77 had a severe outcome (35% of Inpatient). Consistent with previous studies, males and individuals older than 65 years old had increased risk of inpatient admission. Notably, individuals self-identifying as Hispanic or Latino constituted an increasing percentage of COVID-19 patients as disease severity escalated, comprising 24% of those testing positive, but 40% of those with a severe outcome, a disparity that remained after correcting for medical co-morbidities. Cardiovascular disease, hypertension, and renal disease were premorbid risk factors present before SARS-CoV-2 PCR testing associated with COVID-19 susceptibility. Less well-established risk factors for COVID-19 susceptibility included pre-existing dementia (odds ratio (OR) 5.2 [3.2-8.3], p=2.6 x 10-10), mental health conditions (depression OR 2.1 [1.6-2.8], p=1.1 x 10-6) and vitamin D deficiency (OR 1.8 [1.4-2.2], p=5.7 x 10-6). Renal diseases including end-stage renal disease and anemia due to chronic renal disease were the predominant premorbid risk factors for COVID-19 inpatient admission. Other less established risk factors for COVID-19 inpatient admission included previous renal transplant (OR 9.7 [2.8-39], p=3.2x10-4) and disorders of the immune system (OR 6.0 [2.3, 16], p=2.7x10-4). Prior use of oral steroid medications was associated with decreased COVID-19 positive testing risk (OR 0.61 [0.45, 0.81], p=4.3x10-4), but increased inpatient admission risk (OR 4.5 [2.3, 8.9], p=1.8x10-5). We did not observe that prior use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers increased the risk of testing positive for SARS-CoV-2, being admitted to the hospital, or having a severe outcome. This study involving direct EHR extraction identified known and less well-established demographics, and prior diagnoses and medications as risk factors for COVID-19 susceptibility and inpatient admission. Knowledge of these risk factors including marked ethnic disparities observed in disease severity should guide government policies, identify at-risk populations, inform clinical decision making, and prioritize future COVID-19 research.</jats:p>

Mortality and Disease Severity Among COVID-19 Patients Receiving Renin-Angiotensin System Inhibitors: A Systematic Review and Meta-analysis

“…The characteristics of the shortlisted studies are summarized in Table 1. Among shortlisted studies, 23 studies were from China , nine studies were from Italy [64][65][66][67][68][69][70][71][72], ten studies were from the United States [83][84][85][86][87][88][89][90][91][92], four studies were from South Korea [75][76][77][78], three studies were from France [60][61][62], two studies were from Spain [79,80], one study each was from Belgium [35], Denmark [59], Hong Kong [63], Kuwait [73], Singapore [74], Turkey [81], and the United Kingdom [82]; and one study included data from 38 countries [93]. There were 24 studies that included hypertensive patients exclusively (100%) [36, 38, 39, 43-45, 47, 48, 50-52, 54, 56, 58, 66, 71, 72, 75, 78, 81, 87-89, 91].…”

“…The comparison of mortality and clinical severity outcomes between ACEI/ARB users and non-ACEI/ARB users with COVID-19 is summarized in [35,40,52,56,59,61,63,66,74,75,78,80,84,89,90,92] provided adjusted estimates for severe/critical disease with the use of an ACEI/ ARB relative to the non-use of an ACEI/ARB. , it was unclear whether the entire included cohort of patients was followed until discharge/death.…”

“…Ten studies [35,40,61,63,66,75,78,89,90,92] were regarded as 'fair', with scores of 4-6 points. Five studies [52,59,74,80,84] were considered 'poor' (i.e., scored less than 4 points) in the quality assessment.…”

“…The main quality issue noticed in 14 studies [35,40,52,59,61,63,66,74,78,80,84,89,90,92] was the comparison of cohorts with inadequate adjustment for confounders that may influence the estimated risk of severe/critical disease associated with the use of ACEIs/ARBs. Another major issue detected during quality assessment in 12 studies [35,52,59,61,66,74,75,78,80,84,90,92] was the inability to ascertain the exposure to ACEIs/ARBs during the course of illness, where the possibility of discontinuation of ACEIs/ARBs upon COVID-19 diagnosis could not be ruled out based on the study design. Similarly, 12 studies [40,52,59,61,63,74,75,78,84,89,90,92] were not able to demonstrate that severe/critical outcome was not present at the start of the study based on their study design.…”

“…Another major issue detected during quality assessment in 12 studies [35,52,59,61,66,74,75,78,80,84,90,92] was the inability to ascertain the exposure to ACEIs/ARBs during the course of illness, where the possibility of discontinuation of ACEIs/ARBs upon COVID-19 diagnosis could not be ruled out based on the study design. Similarly, 12 studies [40,52,59,61,63,74,75,78,84,89,90,92] were not able to demonstrate that severe/critical outcome was not present at the start of the study based on their study design. In 11 studies [35,52,59,63,66,74,75,78,80,84,90], it was unclear whether the entire cohort of patients was followed until discharge/death.…”