Characteristics and Clinical Outcomes of Adult Patients Hospitalized with COVID-19 — Georgia, March 2020

SARS-CoV-2, the novel coronavirus that causes coronavirus disease 2019 (COVID-19), was first detected in the United States during January 2020 (1). Since then, >980,000 cases have been reported in the United States, including >55,000 associated deaths as of April 28, 2020 (2). Detailed data on demographic characteristics, underlying medical conditions, and clinical outcomes for persons hospitalized with COVID-19 are needed to inform prevention strategies and community-specific intervention messages. For this report, CDC, the Georgia Department of Public Health, and eight Georgia hospitals (seven in metropolitan Atlanta and one in southern Georgia) summarized medical record-abstracted data for hospitalized adult patients with laboratory-confirmed* COVID-19 who were admitted during March 2020. Among 305 hospitalized patients with COVID-19, 61.6% were aged <65 years, 50.5% were female, and 83.2% with known race/ethnicity were non-Hispanic black (black). Over a quarter of patients (26.2%) did not have conditions thought to put them at higher risk for severe disease, including being aged ≥65 years. The proportion of hospitalized patients who were black was higher than expected based on overall hospital admissions. In an adjusted time-to-event analysis, black patients were not more likely than were nonblack patients to receive invasive mechanical ventilation† (IMV) or to die during hospitalization (hazard ratio [HR] = 0.63; 95% confidence interval [CI] = 0.35-1.13). Given the overrepresentation of black patients within this hospitalized cohort, it is important for public health officials to ensure that prevention activities prioritize communities and racial/ethnic groups most affected by COVID-19. Clinicians and public officials should be aware that all adults, regardless of underlying conditions or age, are at risk for serious illness from COVID-19.

management. Data were collected from a convenience sample of 305 patients at seven hospitals in metropolitan Atlanta (five community hospitals, one university hospital, and one public hospital) and one community hospital in southern Georgia. Patients were selected sequentially from lists provided in real time by hospitals from a total of 698 patients aged ≥18 years who were hospitalized with laboratory-confirmed COVID-19 during March 1-March 30, 2020, including stays for observation and deaths in the emergency department. Over a 3-week period, data were abstracted from electronic medical records and recorded using Research Electronic Data Capture software (version 8.8.0; Vanderbilt University) (3). Hospitalizations for patients transferred between participating hospitals or admitted multiple times to the same hospital were analyzed as a single hospitalization. Data on patient race/ethnicity, age, sex, body mass index (BMI), insurance status, residence (e.g., in a longterm care facility), risk factors for severe COVID-19 (based on currently available data and clinical expertise) § (4), and outcomes were abstracted from medical records. Race was categorized as black (non-Hispanic) or nonblack (all other racial/ ethnic groups), and age was analyzed in three groups: 18-49, 50-64, and ≥65 years. Fisher's exact tests for proportions and the Wilcoxon rank sum test or the Kruskal-Wallis H test for medians were used to test differences identified in descriptive analyses. Multivariable Cox proportional-hazards analysis was performed on the association between race and time to meeting a composite outcome of IMV or death, adjusting for age, sex, BMI, hospital, admission date, and underlying medical conditions (selected through a stepwise Akaike information criterion approach, which balances a model's fit against its complexity); censoring was used to account for patients still § Persons aged ≥65 years, persons living in a nursing home or long-term care facility, persons of any age with underlying medical conditions (particularly if the condition is not well controlled), including chronic lung disease or moderate to severe asthma, serious heart conditions, immunocompromise (including cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled human immunodeficiency virus infection or acquired immunodeficiency syndrome, prolonged use of corticosteroids and other immune system-weakening medications), smoking, severe obesity (body mass index ≥40 kg per m 2 ), diabetes mellitus, chronic kidney disease undergoing dialysis, or liver disease. hospitalized without receiving IMV. P-values <0.05 were considered statistically significant. R statistical software (version 3.6.3; The R Foundation) was used to conduct all analyses. Among 305 patients hospitalized with COVID-19, the median age was 60 years (range = 23-95 years, interquartile range [IQR] = 46-69 years) ( Figure 1); 50.5% of patients were female, and 284 (93%) were hospitalized in metropolitan Atlanta. Data on race/ethnicity were available for 297 (97.4%) patients, among whom, 247 (83.2%) were black, 32 (10.8%) were non-Hispanic white, eight (2.7%) were non-Hispanic Asian or Pacific Islander, and 10 (3.4%) were Hispanic ( Figure 2). Median age was not significantly different between black patients (60 years, IQR = 45.5-69.0 years) and nonblack patients (64.5 years, IQR = 44.8-74.0 years). Most patients had private insurance (40.1%) or Medicare (33.4%); 10.9% had Medicaid, and 14.9% were uninsured. Compared with nonblack patients, black patients were more likely to have Medicaid (13.5% versus 0.0%, p = 0.002) but not more likely to be uninsured. Overall, 20 (6.6%) patients resided in longterm care facilities before hospitalization. Current smoking was reported for 5.2% of patients.
Among 281 (92.1%) patients who were no longer hospitalized at the time of data abstraction, 48 (17.1%) died. Case fatality among patients aged 18-49 years, 50-64 years, and ≥65 years was 3.4%, 9.8%, and 35.6%, respectively (p<0.001). Black patients were not more likely than were nonblack patients to receive IMV, to die, or to experience the composite outcome of IMV or death ( Figure 2). Among patients without high-risk conditions, 22.5% were admitted to the ICU, 15.0% received IMV, and 5.1% died while in the hospital. As of April 24, 2020, 24 (7.9%) patients remained hospitalized, including 14 (58.3%) in the ICU and nine (37.5%) on IMV. Overall, the estimated percentage of deaths among patients who received ICU care ranged from 37.0%, assuming all remaining ICU patients survived, to 48.7%, assuming all remaining ICU patients died. In an adjusted time-to-event analysis of IMV or death as a composite outcome, no significant difference was found between black and nonblack patients (HR = 0.63; 95% CI = 0.35-1.13).

Discussion
This report characterizing a cohort of hospitalized adults with COVID-19 in Georgia (primarily metropolitan Atlanta) found that most patients in the cohort were black, and black patients had a similar probability of receiving IMV or dying during hospitalization compared with nonblack patients. Although a larger proportion of older patients had worse outcomes (IMV or death), a considerable proportion of patients aged 18-64 years who lacked high-risk conditions received ICU-level care and died (23% and 5%, respectively). Estimated  case fatality among patients who received ICU care was high (37%-49%) but comparable with that observed in a smaller case series of COVID-19 patients in the state of Washington (5). Among hospitalized patients, 26% lacked high-risk factors for severe COVID-19, and few patients (7%) lived in institutional settings before admission, suggesting that SARS-CoV-2 infection can cause significant morbidity in relatively young persons without severe underlying medical conditions. Community mitigation recommendations (e.g., social distancing) should be widely instituted, not only to protect older adults and those with underlying medical conditions, but also to prevent the spread of SARS-CoV-2 among persons in the general population who might not consider themselves to be at risk for severe illness (6). The proportion of hospitalized patients who were black was higher than expected based on overall hospitalizations. At four affiliated hospitals, which accounted for 67% of patients in the cohort, 80% of cohort patients were black compared with 47% of hospitalized patients overall during March 2020 (D. Murphy, personal communication, April 7, 2020). Similarly, COVID-NET, which conducts population-based surveillance for laboratory-confirmed COVID-19-associated hospitalizations across 14 sites nationwide, ¶ found that black persons were disproportionately represented among hospitalized patients with COVID-19 (7). It is important to continue ongoing efforts to understand why black persons are disproportionately hospitalized for COVID-19, including the role of social and economic factors (including occupational exposures) in SARS-CoV-2 acquisition risk. It is critical that public health officials ensure that prevention activities prioritize communities and racial groups most affected by COVID-19.  The findings in this report are subject to at least three limitations. First, the data are from a convenience sample of hospitalized adult patients in metropolitan Atlanta and southern Georgia, and data collection for this assessment was limited by the intention to conduct the investigation quickly. These patients do not necessarily represent all hospitalized patients with COVID-19 at those hospitals, or within Georgia. Second, patients were not tracked after discharge in this investigation. Finally, race and ethnicity were abstracted from medical records, and methods for recording these categories might have differed across hospitals, which could result in misclassification.
This report provides valuable clinical data on a large cohort of hospitalized patients. Although frequency of IMV and fatality did not differ by race, black patients were disproportionately represented among hospitalized patients, reflecting greater severity of COVID-19 among this population. Public officials should consider racial differences among patients affected by COVID-19 when planning prevention activities. Approximately one quarter of patients had no high-risk

Summary
What is already known about this topic?
Older adults and persons with underlying medical conditions are at higher risk for severe COVID-19. Non-Hispanic black patients are overrepresented among hospitalized U.S. COVID-19 patients.
What is added by this report?
In a cohort of 305 hospitalized adults with COVID-19 in Georgia (primarily metropolitan Atlanta), black patients were overrepresented, and their clinical outcomes were similar to those of nonblack patients. One in four hospitalized patients had no recognized risk factors for severe COVID-19.
What are the implications for public health practice?
Prevention activities should prioritize communities and racial groups most affected by severe COVID-19. Increased awareness of the risk for serious illness among all adults, regardless of underlying medical conditions or age, is needed.
conditions, and 5% of these patients died, suggesting that all adults, regardless of underlying conditions or age, are at risk for serious COVID-19-associated illness.