Letter to the Editor
COVID-19 mortality and health-care resources: Organization
Mortalidad de COVID-19 y recursos sanitarios: organización
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Immovilli, N. Morelli, E. Rota, D. Guidetti" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Immovilli" "email" => array:1 [ 0 => "paolo.immovilli.md@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Morelli" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Rota" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "D." "apellidos" => "Guidetti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Neurology Unit, Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Neurology Unit, ASL Alessandria, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mortalidad de COVID-19 y recursos sanitarios: organización" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 715 "Ancho" => 2174 "Tamanyo" => 76141 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) The correlation between the case fatality rate and the COVID-19 incidence; (b) the inverse correlation between the case fatality rate and the ICU admission rate (number of people admitted to the ICU to total inpatient rate).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ji and colleagues<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> plotted COVID-19 mortality against incidence and demonstrated a statistically significant correlation, which highlighted a possible link between mortality and health-care burden; we recently found a similar association between case fatality rate (CFR) and intensive care unit to total inpatient admission rate (ICUAR).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Extending our previous analysis over time on the cumulative data from February 21<span class="elsevierStyleSup">st</span> to April 18<span class="elsevierStyleSup">th</span>, and including COVID-19 incidence, we evaluated CFR and ICUAR on 175,925 cases, 27,740 inpatients, 2733 intensive care unit (ICU) inpatients, 23,227 deaths: the CFR was 13.2%, and the number of patients admitted in ICU varied along time, reaching a peak of 4068 on April 3<span class="elsevierStyleSup">rd</span> and reducing to 2733 on April 18<span class="elsevierStyleSup">th</span> (32.8% reduction in 2 weeks).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The COVID-19 incidence and ICU capability varied widely amongst the Italian Regions: the average incidence was 28.6 per 10,000 people (range 5.2–85.6) and the average ICUAR was 11.8% (range 4.4–22.7).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are some particular issues involved in the estimation of CFR in Italy: the high average age of the Italian population, the definition of COVID-19-related deaths, the pharyngeal swab testing strategy employed and the CFR variation in different epidemic time-frame. It has been postulated that the confirmed diagnosis of milder cases could increase with the number of swabs taken.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A univariate analysis of Italian regional data showed a strong correlation between CFR and COVID-19 incidence (<span class="elsevierStyleItalic">R</span> 0.715, <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span> 0.511, <span class="elsevierStyleItalic">p</span>-value 0.000), an inverse correlation between CFR and ICUAR (<span class="elsevierStyleItalic">R</span> −0.466, <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span> 0.217, <span class="elsevierStyleItalic">p</span>-value 0.033) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The pharyngeal swab per 10,000 people did not correlate with the CFR (<span class="elsevierStyleItalic">p</span>-value 0.368).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The multivariate analysis showed that CFR was only associated with COVID-19 incidence (<span class="elsevierStyleItalic">p</span>-value 0.001), but neither with ICUAR (<span class="elsevierStyleItalic">p</span>-value 0.172), nor with pharyngeal swab per 10,000 people (<span class="elsevierStyleItalic">p</span>-value 0.221).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The different COVID-19 incidence and ICU capability in the Italian Regions showed that mortality was linked to high incidence and ICU capability.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our previous analysis was done during the continuous everyday increasing of ICU patients, which peaked on April 3<span class="elsevierStyleSup">rd</span>, whether now we included two weeks of decreasing pressure on ICU: the association between CFR and ICAR is still present, but in the multivariate regression model only the incidence had a significant effect. Lombardy was the epicenter of the out-break and the region with higher CFR: it was an outlier, probably contributing to reduce the coefficient of determination (<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span>) in the correlation between CFR and ICUAR.</p><p id="par0045" class="elsevierStylePara elsevierViewall">During different time-frame of such a huge outbreak the key factors associated with CFR may play different roles: the incidence seems to be strongly associated with CFR, but the ICUAR could be associated especially during the increasing of out-break when the ICU capability could be overwhelmed. According to this hypothesis different health-care resources should be implemented in different out-break time-frame.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">On behalf of all authors, the corresponding author states that there is no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:2 [ "identificador" => "xack546448" "titulo" => "Acknowledgments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 715 "Ancho" => 2174 "Tamanyo" => 76141 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) The correlation between the case fatality rate and the COVID-19 incidence; (b) the inverse correlation between the case fatality rate and the ICU admission rate (number of people admitted to the ICU to total inpatient rate).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Potential association between COVID-19 mortality and healthcare resource availability" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Ji" 1 => "Z. Ma" 2 => "M.P. Peppelenbosch" 3 => "Q. Pan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Lancet Glob Health" "fecha" => "2020" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "CVID-19 mortality and ICU admission: the Italian experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Immovilli" 1 => "N. Morelli" 2 => "E. Antonucci" 3 => "G. Radaelli" 4 => "M. Barbera" 5 => "D. Guidetti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13054-020-02957-9" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2020" "volumen" => "24" "paginaInicial" => "228" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32414403" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "<a target="_blank" href="http://opendatadpc.maps.arcgis.com/apps/opsdashboard/index.html#/b0c68bce2cce478eaac82fe%2038d4138b1">http://opendatadpc.maps.arcgis.com/apps/opsdashboard/index.html#/b0c68bce2cce478eaac82fe 38d4138b1</a> (accessed 18.04.20)" ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Onder" 1 => "G. Rezza" 2 => "S. Brusaferro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2020.4683. Published online: March 23" "Revista" => array:3 [ "tituloSerie" => "JAMA" "fecha" => "2020" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9676687" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack546448" "titulo" => "Acknowledgments" "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">The author thanks The Italian Civil Protection Department for sharing the data on line and Mrs Barbara Ward for her linguistic advice.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004500000006/v1_202107200621/S2173572721000837/v1_202107200621/en/main.assets" "Apartado" => array:4 [ "identificador" => "64604" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004500000006/v1_202107200621/S2173572721000837/v1_202107200621/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572721000837?idApp=WMIE" ]
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