UMR Unité des Virus Émergents (UVE Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France.
Department of Microbiology & Immunology, School of Medicine, Georgetown University, Washington, DC, United States of America.
PLoS One. 2020 Dec 15;15(12):e0243606. doi: 10.1371/journal.pone.0243606. eCollection 2020.
When the population risk factors and reporting systems are similar, the assessment of the case-fatality (or lethality) rate (ratio of cases to deaths) represents a perfect tool for analyzing, understanding and improving the overall efficiency of the health system. The objective of this article is to estimate the influence of the hospital care system on lethality in metropolitan France during the inception of the COVID-19 epidemic, by analyzing the spatial variability of the hospital case-fatality rate (CFR) between French districts. In theory, the hospital age-standardized CFR should not display significant differences between districts, since hospital lethality depends on the virulence of the pathogen (the SARS-CoV-2 virus), the vulnerability of the population (mainly age-related), the healthcare system quality, and cases and deaths definition and the recording accuracy. We analyzed hospital data on COVID-19 hospitalizations, severity (admission to intensive care units for reanimation or endotracheal intubation) and mortality, from March 19 to May 8 corresponding to the first French lockdown. All rates were age-standardized to eliminate differences in districts age structure. The results show that the higher case-fatality rates observed by districts are mostly related to the level of morbidity. Time analysis shows that the case-fatality rate has decreased over time, globally and in almost all districts, showing an improvement in the management of severe patients during the epidemic. In conclusion, it appears that during the first critical phase of COVID-19 ramping epidemic in metropolitan France, the higher case-fatality rates were generally related to the higher level of hospitalization, then potentially related to the overload of healthcare system. Also, low hospitalization with high case-fatality rates were mostly found in districts with low population density, and could due to some limitation of the local healthcare access. However, the magnitude of this increase of case-fatality rate represents less than 10 per cent of the average case-fatality rate, and this variation is small compared to much greater variation across countries reported in the literature.
当人群风险因素和报告系统相似时，评估病死率（病例与死亡人数的比例）是分析、理解和提高卫生系统整体效率的完美工具。本文的目的是通过分析法国各地区医院病死率（CFR）的空间变异性，来评估法国大都市地区医院医疗系统对 COVID-19 疫情初期病死率的影响。从理论上讲，由于医院病死率取决于病原体的毒力（SARS-CoV-2 病毒）、人群的脆弱性（主要与年龄有关）、医疗保健系统的质量以及病例和死亡的定义和记录的准确性，各地区之间的医院年龄标准化病死率不应有显著差异。我们分析了 3 月 19 日至 5 月 8 日（对应法国第一次封锁）期间 COVID-19 住院、严重程度（入住重症监护病房进行复苏或气管插管）和死亡率的医院数据。所有比率均按年龄标准化，以消除各地区年龄结构的差异。结果表明，观察到的病死率较高的地区主要与发病率水平有关。时间分析表明，病死率随着时间的推移而下降，全球范围内和几乎所有地区都有所下降，这表明在疫情期间对重症患者的管理有所改善。总之，在 COVID-19 大流行的法国大都市地区的第一个关键阶段，较高的病死率通常与较高的住院率有关，然后可能与医疗保健系统的过载有关。此外，病死率较高的低住院率主要出现在人口密度较低的地区，这可能是由于当地医疗服务获取存在一些限制。然而，病死率的这种增加幅度不到平均病死率的 10%，与文献中报告的各国之间更大的变化相比，这种变化很小。
