AUTHOR=Ricoca Peixoto Vasco , Vieira André , Aguiar Pedro , Carvalho Carlos , Thomas Daniel , Sousa Paulo , Nunes Carla , Abrantes Alexandre 

TITLE=Difference in determinants of ICU admission and death among COVID-19 hospitalized patients in two epidemic waves in Portugal: possible impact of healthcare burden and hospital bed occupancy on clinical management and outcomes, March–December 2020

JOURNAL=Frontiers in Public Health

VOLUME=Volume 11 - 2023

YEAR=2023

URL=https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2023.1215833

DOI=10.3389/fpubh.2023.1215833

ISSN=2296-2565

ABSTRACT=Aim
Identify risk factors for COVID-19 intensive care unit (ICU) admission and death among hospitalized cases in Portugal, and variations from the first to the second wave in Portugal, March-December 2020 
Introduction
Determinants of ICU admission and death for COVID-19 need further understanding and may change over time. We used hospital discharge data (ICD-10 diagnosis-related groups) to identify factors associated with COVID-19 outcomes in two epidemic periods with different hospital burden to inform policy and practice.
Methods	
We conducted a retrospective cohort study including all hospitalized cases of laboratory-confirmed COVID-19 in the Portuguese NHS hospitals, discharged from March to December 2020. We calculated sex, age, comorbidities attack rates by period and calculated adjusted relative risks (aRR) for the outcomes of admission to ICU and death, using Poisson regressions. We tested effect modification between two distinct pandemic periods(March-Sep/Oct-Dec) with lower and higher hospital burden, in other determinants. 
Results
Of 18,105 COVID-19 hospitalized cases, 10.22% were admitted to ICU and 20.28% died in hospital during the hospitalization before discharge. Being aged 60-69 years (when compared with those aged 0-49) was the strongest independent risk factor for ICU admission (aRR 1.91, 95%CI 1.62-2.26). Unlike ICU admission, risk of death increased continuously with age and in the presence of specific comorbidities. Risk factors for ICU admission and death differed by epidemic period. Testing interactions, in the period with high hospital burden, those aged 80-89, woman and those with specific comorbidities had a significantly lower aRR for ICU admission. Risk of death increased in the second period for those with dementia and diabetes.

Discussion and Conclusions
Different patient profiles were identified for ICU and deaths among COVID-19 hospitalized patients in different pandemic periods with lower and higher hospital burden, possibly implying changes in clinical practice, priority setting or clinical presentation that should be further investigated and discussed considering impacts of services higher burden in health outcomes, to inform preparedness, healthcare workforce planning and pandemic prevention measures.