Factors that impacted poor outcomes in patients with COVID-19 were closely related to age and comorbidities, not rheumatic disease diagnosis. Increased risk was seen in patients receiving glucocorticoids.
There was no significant link between rheumatic disease (RD) and hospitalization or death in US veterans who developed COVID-19, according to a study published in Open Rheumatology.1 Factors that did impact poor outcomes were closely related to age and comorbidities, which were similar among the general population. The only increased risk was seen in patients receiving glucocorticoids.
“Individuals with autoimmune rheumatic disease (RD) are considered to be at increased risk for infection. However, few US population-based studies have assessed whether these patients are at increased risk of hospitalization or death due to COVID-19 compared with those without RD,” investigators stated.”
The retrospective study used data from the national Veterans Affairs Health Care System (VAHCS) Veterans Affairs Corporate Data Warehouse (CDW) and analyzed patients who tested positive for SARS-CoV-2 between March 2 and September 30, 2020. The CDW contained information about inpatient and outpatient diagnoses, medication usage, laboratory codes, and dates of death.
RDs included rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), polymyalgia rheumatica, and sarcoidosis. Veterans who received antirheumatic medications, such as disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids, for at least 28 days within the past year were entered into the RD cohort. Covariates were listed as age, race/ethnicity, body mass index, geographic region, and marital status. Behavioral risks, such as tobacco use, alcohol abuse, and comorbid conditions were also recorded.
Investigators compared patients with and without RD using both propensity score matching (PSM) and multivariate logistic regression. The primary outcome was hospitalization or death after COVID-19 diagnosis.
A total of 26,116 veterans with COVID-19 were included in the study, with 501 (1.9%) patients in the RD cohort. The most common RD was RA (44.3%) and 29.0% were currently being treated with oral glucocorticoids. Patient characteristics were similar between both groups.
Glucocorticoid usage increased odds of poor outcomes (odds ratio [95% confidence interval] for hospitalization or death: 1.33 [1.20-1.48] for doses >0 and ≤10 mg/day; 1.29 [1.09-1.52] for doses >10 mg/day).
Older, Black or Hispanic, male patients, and current tobacco users or those with other comorbidities were at a higher risk of being hospitalized or dying from COVID-19 complications.
The PSM model 1 included factors such as age, sex, ethnicity, and month of positive SARS-CoV-2 test. PSM model 2 included individual comorbidities. In the PSM model 1, investigators examined 501 veterans with RD and compared them with 501 controls. In the PSM model 2, 497 veterans with RD and 497 controls were observed. Before PSM, patients with RD were more likely to have poor outcomes (37.7% vs 28.6% hospitalized [P = 0.002] and 6.4% vs 4.5% deaths, respectively). However, after PSM analysis, RD was not a contributing factor for worse outcomes. Hypertension, heart disease, and pneumonia were significant predictors of poor outcomes in both matched and unmatched models.
The study was strengthened by the large population of veterans analyzed, and including details such as diagnosis, medications, and laboratory studies. However, it was limited by the patient population, which was generally older and male, thus hindering generalizability. Additionally, disease activity was not reported, which has been proven to be an important factor in predicting outcomes. Glucocorticoid exposure may have been misclassified as it was defined as a prescription any time during the 12 months preceding COVID-19 diagnosis. Further, glucocorticoid usage may have been underestimated as it was assumed a once-daily dose in patients with whom daily dose could not be determined by available VAHCS data. There is also the possibility that patients died of COVID-19 after a 30-day hospitalization period.
“Our study suggests that veterans with RD do not appear to be at higher risk for poor COVID-19 outcomes above the risk conferred by age and other comorbidities; however, glucocorticoid use did appear to increase risk of poor outcomes, even at lower doses,” investigators concluded.
Schmajuk G, Montgomery AD, Leonard S, et al. Factors Associated With Hospitalization and Death After COVID-19 Diagnosis Among Patients With Rheumatic Disease: An Analysis of Veterans Affairs Data [published online ahead of print, 2021 Aug 23]. ACR Open Rheumatol. 2021;10.1002/acr2.11328. doi:10.1002/acr2.11328