Differences and Similarities Among COVID-19 Patients Treated in Seven ICUs in Three Countries Within One Region: An Observational Cohort Study

Abstract

Objectives: To investigate healthcare system-driven variation in general characteristics, interventions, and outcomes in coronavirus disease 2019 (COVID-19) patients admitted to the ICU within one Western European region across three countries.

Design: Multicenter observational cohort study.

Setting: Seven ICUs in the Euregio Meuse-Rhine, one region across Belgium, The Netherlands, and Germany.

Patients: Consecutive COVID-19 patients supported in the ICU during the first pandemic wave.

Interventions: None.

Measurements and main results: Baseline demographic and clinical characteristics, laboratory values, and outcome data were retrieved after ethical approval and data-sharing agreements. Descriptive statistics were performed to investigate country-related practice variation. From March 2, 2020, to August 12, 2020, 551 patients were admitted. Mean age was 65.4 ± 11.2 years, and 29% were female. At admission, Acute Physiology and Chronic Health Evaluation II scores were 15.0 ± 5.5, 16.8 ± 5.5, and 15.8 ± 5.3 (p = 0.002), and Sequential Organ Failure Assessment scores were 4.4 ± 2.7, 7.4 ± 2.2, and 7.7 ± 3.2 (p < 0.001) in the Belgian, Dutch, and German parts of Euregio, respectively. The ICU mortality rate was 22%, 42%, and 44%, respectively (p < 0.001). Large differences were observed in the frequency of organ support, antimicrobial/inflammatory therapy application, and ICU capacity. Mixed-multivariable logistic regression analyses showed that differences in ICU mortality were independent of age, sex, disease severity, comorbidities, support strategies, therapies, and complications.

Conclusions: COVID-19 patients admitted to ICUs within one region, the Euregio Meuse-Rhine, differed significantly in general characteristics, applied interventions, and outcomes despite presumed genetic and socioeconomic background, admission diagnosis, access to international literature, and data collection are similar. Variances in healthcare systems' organization, particularly ICU capacity and admission criteria, combined with a rapidly spreading pandemic might be important drivers for the observed differences. Heterogeneity between patient groups but also healthcare systems should be presumed to interfere with outcomes in coronavirus disease 2019.

Figure 1.

Flow chart. COVID = coronavirus disease, Maastricht UMC+ = Maastricht University Medical Center +, RWTH = Rheinisch Westfälische Hochschule.

Figure 2.

Patient transportation (A) and ICU capacity before and during the pandemic wave (B). A, The arrows represent the transportation of patients (exact amount displayed as number) between ICUs (displayed as dots) inside and outside the Euregio Meuse-Rhine (displayed as arrows from outside circle to inside and inversely). B, General ICU capacity compared with maximum ICU capacity during first coronavirus disease 2019 wave reported in total number of ICU beds per center (i.e.16 to 32 means that VieCuri Hospital Venlo had 16 operational ICU beds before the pandemic, which was upgraded to 32 ICU beds due to pandemic needs). For Jessa and ZOL Hospital, the total number of beds comprises ICUs and cardiovascular care units. RWTH = Rheinisch Westfälische Hochschule, ZOL = Ziekenhuis Oost-Limburg.