Patients hospitalized with Covid-19 are surviving at higher rates than in the early days of the pandemic, gains that data and interviews with experts suggest are driven by a more refined understanding of the disease and how to treat it — and, crucially, less strain on hospitals that had been inundated at times.
Other factors have contributed to the improved outcomes: Steroids that help save some lives are being used more widely, and people infected after the initial surge were, as a whole, younger and arrived at the hospital earlier in the course of the disease.
But clinicians warn that this progress won’t withstand what happens when crushes of patients again overwhelm hospitals, as is now occurring in dozens of U.S. states. With the country setting new records of hospitalizations daily, care is getting threatened, and death rates — not just deaths — could increase.
“We’re going to have lives lost that shouldn’t be lost,” said Kelly Cawcutt, an infectious diseases and critical care physician at the University of Nebraska Medical Center.
Comparing mortality rates from one point of the pandemic to another is challenging. Testing was so limited in the early days, with many more cases being missed than now, that it inflated how deadly the coronavirus seemed.
But some studies and other data have started to show patients sick enough to need care at the hospital are more likely to survive now. An analysis prepared for STAT by the independent nonprofit FAIR Health found that the mortality rate of select hospitalized Covid-19 patients in the U.S. dropped from 11.4% in March to below 5% in June, a threshold the rate has stayed below since. In September, the most recent month available, the mortality rate was 3.7%, according to FAIR Health’s data, which are based on hospital coding information for approximately 100 million people with private insurance, including Medicare Advantage plans.
Patients have also been leaving the hospital faster, according to the data. The average length of stay declined from 10.5 days in March to 4.6 days in September.
The FAIR Health data in this analysis do not account for patients’ age and underlying health conditions. It’s also likely that death rates for patients without private insurance are higher than for those with commercial plans.
But studies — some of which have controlled for such factors as age, race, and baseline health — have also found improvements in survival over the months. “Mortality was significantly and progressively lower over the course of the study period,” researchers in New York wrote in one paper, which looked at the death rate in one health system from March — when it was 25.6% — to August — when it 7.6%. In an English study, survival among 5,715 ICU patients increased from 58% in late March to 80.4% by the end of June. Another study out of New York City estimated the infection-fatality rate for the city’s entire population dropped from 6.7% at the beginning of April to 4.2% by the end of May for people 65 to 74 years old, and from 19.1% to 10.4% over the same period for people 75 and older.
The trend has been seen elsewhere as well, as medical teams worldwide have built an understanding of how to treat the illness, which wasn’t seen until a year ago.
“The mortality has reduced and that is because we know so much more,” Maria Van Kerkhove, the World Health Organization’s Covid-19 technical lead, said last month. “Our clinicians, our nurses, our medical professionals have direct experience with this virus, are better trained, are better experienced and are providing that lifesaving care.”
Now, in the U.S., clinicians are having to put that knowledge to use for more patients than ever before.
When patients started arriving at hospitals with Covid-19, medical teams were dealing with a virus, called SARS-CoV-2, they had never seen. U.S. doctors got some advice from colleagues in China and Italy who dealt with the pandemic first, but at that point, there were no approved therapies for any coronavirus infection.
At first, medical teams thought they were dealing solely with a severe respiratory infection. They in turn put many patients on ventilators, hoping it could buy them time to fight off the illness while supporting their oxygen levels.
“We thought it was just a ventilation problem,” said Mark Rosenberg, the chair of emergency medicine at St. Joseph’s Health in New Jersey and president of the American College of Emergency Physicians.
But soon, clinicians started noticing other issues. On top of the respiratory attack, some patients developed blood clots and had strokes. Some had heart issues or kidney failure. There was a long-lasting inflammatory response that damaged tissues. Considering that some people with Covid-19 were asymptomatic throughout the course of their infection, it was notable that many who got sick got really sick — and stayed sick for a long time.
Even the respiratory symptoms had their idiosyncrasies. Some Covid-19 patients who had oxygen levels that seemed to blare they needed intubation might be chatting, whereas with other diseases they would have been straining to breathe. “Happy hypoxics,” their nickname became. Clinicians quickly realized that fewer of these patients needed to go through the invasive process of being put on ventilators. Instead, simpler interventions could boost their oxygen levels sufficiently.
Covid-19 patients also did not fare well on ventilators, and often remained on them for weeks. “Once a patient has been put on a ventilator, it can be very difficult to wean them off,” said Rachael Lee, an infectious disease physician at the University of Alabama at Birmingham.
Medical teams instead started delivering oxygen through helmets, masks, and nasal cannulas, and encouraged people to lie on their stomachs. Called proning, the technique is also done with people on ventilators. It opens up people’s lungs, including the parts that haven’t been damaged by the infection, and makes it easier to breathe. Supplemental oxygen and proning can keep patients’ oxygen levels up until their bodies are able to fend off the infection.
Now, some patients who seem stable are being sent home with extra oxygen and told to monitor their symptoms and oxygen levels. Ventilators are restricted for the patients who can’t sustain oxygen levels even with less invasive measures and whose illnesses continue to progress.
“We don’t intubate people as quickly as we used to, and we don’t admit them like we used to,” Rosenberg said. He added that if his hospital had the same patient volume it has now back in the spring, dozens would have been on ventilators. “As of this morning, we had three,” he said one day this month.
Indeed, according to the FAIR Health data, 18.6% of hospitalized Covid-19 patients were on ventilators in March, compared to 1.5% in September. This likely reflects not just the fact that clinicians are using ventilators less often now, but also that at the beginning of the pandemic, patients in some places were urged to avoid the hospital until they got really sick. Now, people are encouraged to get earlier care, so patients in the hospital are often less sick to begin with.
When people with Covid-19 get severely ill, it’s typically not just the virus causing the damage. In some patients, the immune response that’s mounted to battle the virus shifts into overdrive, wreaking so much internal havoc that it can kill people.
Doctors often turn to immune-dampening steroids in these cases, and in June, a clinical trial showed that the steroid dexamethasone cut deaths in hospitalized Covid-19 patients, with greater benefits in the sickest people. So far, it’s the only therapy shown to have an impact on mortality in clinical trials, and since the spring, steroid use has picked up among hospitalized patients, from 5.6% of patients in March to between 8% and 11% since May, according to the FAIR Health data. Dexamethasone is recommended only for patients who are hospitalized and need supplemental oxygen, to avoid blunting the beneficial immune response the body needs to beat back the virus.
Other therapies have also improved patient care, experts say. As the risk of clotting became known, medical teams were ready to increase the doses of blood thinners that patients in the ICU typically get. Though, in an example of how discordant one case of Covid-19 can be from another, some patients develop bleeding issues, meaning blood thinners aren’t always used. “There are fractured approaches to anticoagulation that are institution or health-system specific, but there is not consensus,” said Lewis Kaplan, the president of the Society of Critical Care Medicine.
Then there’s remdesivir, an antiviral from Gilead Sciences. In one clinical trial, it was shown to reduce the time patients stayed in the hospital, and it’s approved by the Food and Drug Administration. But other research has found limited benefits, particularly on mortality, and last week, the WHO recommended that doctors not give remdesivir to hospitalized patients because there is no evidence it improves survival. Still, some physicians say the drug may help some people — particularly if it can be given early in an infection — and it’s become part of regular care for hospitalized patients in the U.S. Experts also note there aren’t better options that target the virus itself.
Crucially, through clinical trials, experts also began to parse what potential therapies didn’t work, such as the malaria drug hydroxychloroquine, which had been used widely early on after initial small studies suggested it might help. More rigorous trials later showed it had no benefit and might even be harmful to some patients.
Medical interventions alone likely do not explain the improved outcomes over the months. Whom a pathogen infects is a crucial factor in how lethal it is, and younger people, who are less likely to get severe Covid-19 and die than older people, have accounted for an increasing proportion of infections since the spring. Death rates also depend on the underlying health of the population — people who have conditions like obesity, diabetes, or lung diseases face higher risks of more serious disease — and how equipped the local health care system is to take care of patients.
There’s also the fact that in many places, hospitals became less crowded after an initial spring surge, allowing clinicians to provide better care, particularly with their hard-won knowledge of how to treat the disease.
Another hypothesis is that with broader use of masks, infectious people are expelling less virus, meaning that they are exposing others to lower doses of the virus, which perhaps makes them less sick. Some scientists have speculated that changes to the virus, which appear to have made it more transmissible, might have tamed how deadly it is, though that’s not proven.
Whatever the ingredients, there’s been a clear result: “Patients are not crashing as quickly as they did before, and they’re not getting as sick,” said Jeff Doucette, the chief nursing officer at Thomas Jefferson University Hospitals in Philadelphia.
As important a metric as death is, it is just one measure of Covid-19 outcomes. There are plenty of other reasons experts say people should be trying to stave off as much transmission as possible. (And even if mortality rates have dropped, doctors are quick to note that Covid-19 remains deadlier than the flu.)
Even if more people survive their infections, their ordeals don’t always end there. Some “long-haulers” — even those who had mild cases and weren’t hospitalized — have for months had lingering symptoms, including fatigue, forgetfulness, and heart inflammation. Patients who do wind up in the ICU can have lasting physical and mental health issues, what’s called post-intensive care syndrome, or PICS.
One recent study found that of 1,250 patients who had been released from hospitals in Michigan, more than 10% had to go to a nursing or rehabilitation facility. Within 60 days of discharge, 84 of the 1,250 had died, while another 189 were rehospitalized. Many could not return to work because of ongoing health problems.
“They seem to have a very robust form of PICS, and we’re not quite sure how to best treat that,” said Kaplan, also a professor of surgery at the University of Pennsylvania’s Perelman School of Medicine.
For all the gains in Covid-19 treatment, there are still gaps in what clinicians can do. Namely, they need better therapies, particularly those that could prevent people from progressing to more severe illness that requires hospitalization.
“There is a noteworthy absence of treatments proven to be efficacious for patients with early or mild infection,” about 20% of whom will go on to develop more severe illnesses, Anthony Fauci and colleagues at the National Institute of Allergy and Infectious Diseases wrote in a paper this month.
Options are coming. Monoclonal antibody therapies developed for SARS-2 by Eli Lilly and Regeneron received emergency use authorizations from the FDA this month — though they come with a heap of logistical hurdles.
Already, some hospitals are building outpatient infusion centers specifically for patients with Covid-19 to receive the monoclonal antibodies. But the problem is one of supply. The companies say they’ll be able to make hundreds of thousands of doses by the end of the year, but that comes as nearly 200,000 Americans are finding out they’re sick on a given day.
Not all of those people need help fending off the infection. But aside from certain risk factors — including age, weight, and underlying health conditions — it’s difficult to know who would recover fine without the therapy, and whom the therapy could prevent from getting so sick they need to take up hospital beds. And beyond the monoclonals, other treatments for earlier cases aren’t very far in the development process.
When asked what was still needed to improve Covid-19 care, Nebraska’s Cawcutt had a simpler answer than a new therapeutic or technique.
“This is going to sound facetious when I say it, but honestly, preventing it,” she said.
Hospitals in the Midwest, Mountain West, and elsewhere are straining under a crush of patients, with others fearing what’s headed their way. Some have stopped accepting transfers, while others are trying to offload patients to other states. They’re converting other wards into new ICUs. They’re asking retired staff if they’re available. The surge is so widespread that doctors and nurses can’t go to help out in other areas like they did in New York in the spring.
Experts warn that this will affect care. Hospitals are now relying on staff pulled in from other parts of the hospital who haven’t worked in ICUs for years to try to deliver very specialized care. The more Covid-19 patients that are crowding into hospitals, the less well clinicians can help someone who comes in with a heart attack or after a car crash. Some of the highest hospitalization rates are in rural areas and in states that don’t have the baseline capacity that places like Boston and Houston do. One study from Italy estimated that the death toll from the early surge in the Lombardy region could have been 25% lower had there been more ICU access for patients.
“The care just isn’t quite as good or as intensive,” infectious disease physician Andrew Pavia of the University of Utah said of the care being delivered now, with a regular ICU and an overflow ICU already full. The hospital normally provides high-level care to patients from parts of Arizona, Montana, Wyoming, and Idaho, but it is so crowded that it’s having to prioritize Utahns.
“This doesn’t have to do with running out of ventilators yet,” he said. “It just has to do with the fact that to help somebody survive an illness like this requires a great deal of care from very skilled people.”
The Utah health system has also stopped providing Covid-19 patients with ECMO — a way to boost oxygen levels in the blood — because it’s such a time- and labor-intensive process that it meant they couldn’t take care of as many patients. “We have to make those kind of decisions: Do we offer this really intensive kind of therapy to one person, but three or four others may not get an ICU bed because it takes that much staff?” said Kencee Graves, associate chief medical officer at University of Utah Health. Hospital leaders in the state have warned about the potential need to ration care.
To measure hospital capacity, people sometimes narrow in on figures like the number of beds or ventilators. But that neglects what’s really limiting patient care, particularly as more hospitals face increasing staff shortages, clinicians say.
“Everyone talks about do you have enough ventilators,” said Pritish Tosh, an infectious diseases physician and medical director for emergency management at the Mayo Clinic. “But it takes a lot to ventilate a patient. You need an ICU room. You need staff. You need a critical care physician, you need a critical care nurse, you need a respiratory therapist. You also need the supplies. You need the ventilator, you also need the ventilator circuit. You need the medications that are needed to sedate the person. All these sorts of things.”
What’s even more alarming to clinicians than their current hospitalization numbers is that infections keep going up in their states. Those people who are testing positive on a given day were likely infected about a week ago, and those who progress to needing hospital care will take another week to do so. The waves of future patients headed hospitals’ way have already formed. It’s like Indiana Jones seeing the boulder rolling toward him if he were already pinned under a boulder.
“There’s really just this sense of foreboding,” Cawcutt said. “We know what we might see in two weeks, and we know we’re running out of beds right now.” Her medical center already has 10 units full of Covid-19 patients. Cawcutt described it as “looking at a system that is going to break down.”
Last week, Cawcutt and more than 1,700 of her colleagues signed a letter to Nebraskans urging them to do their part to slow the spread of the coronavirus.
“It’s kind of terrifying to think about working so hard to save patients’ lives, when it’s so easy to wear a mask, it’s so easy to do these other things,” she told STAT. “None of us love wearing masks or staying home or social distancing, but we would do that forever to save lives. To not see that sentiment extended in our communities, it’s so frustrating, it’s heartbreaking. It’s really hard to brace for what’s still coming.”