Mortality patterns among COVID‐19 patients in two Saudi hospitals: Demographics, etiology, and treatment

Abstract Background Saudi Arabia (SA) reported its first case of COVID‐19 on 2 March 2020. Mortality varied nationwide; by April 14, 2020, Medina had 16% of SA's total COVID‐19 cases and 40% of all COVID‐19 deaths. A team of epidemiologists investigated to identify factors impacting survival. Methods We reviewed medical records from two hospitals: Hospital A in Medina and Hospital B in Dammam. All patients with a registered COVID‐related death between March and May 1, 2020, were included. We collected data on demographics, chronic health conditions, clinical presentation, and treatment. We analyzed data using SPSS. Results We identified 76 cases: 38 cases from each hospital. More fatalities were among non‐Saudis at Hospital A (89%) versus Hospital B (82%, p < 0.001). Hypertension prevalence was higher among cases at Hospital B (42%) versus Hospital A (21%) (p < 0.05). We found statistically significant differences (p < 0.05) in symptoms at initial presentation among cases at Hospital B versus Hospital A, including body temperature (38°C vs. 37°C), heart rate (104 bpm vs. 89 bpm), and regular breathing rhythms (61% vs. 55%). Fewer cases (50%) at Hospital A received heparin versus Hospital B (97%, p‐value < 0.001). Conclusion Patients who died typically presented with more severe illnesses and were more likely to have underlying health conditions. Migrant workers may be at increased risk due to poorer baseline health and reluctance to seek care. This highlights the importance of cross‐cultural outreach to prevent deaths. Health education efforts should be multilingual and accommodate all literacy levels.

The severity of the disease varies significantly, ranging from asymptomatic infection to the development of severe complications and death. 3 Age, gender, and the presence of co-morbidities have been reported to be contributing factors to COVID-19 severity. [4][5][6][7] Patients with diabetes or chronic obstructive pulmonary disease (COPD) are more likely to have longer hospitalizations, be admitted to intensive care units (ICU), and require mechanical ventilation. 5,8 Conversely, mild prognosis has been reported among pediatric cases.
However, the severity of the infection has also been reported among children affecting up to 5% of the infected patients although compared with adults, children and/or adolescents tend to have a mild COVID-19 course with a good prognosis. [9][10][11] Evidence on the pathology behind the development of the disease has also been variable. At first, it was thought that the virus affects the respiratory tract only; however, reports showed that it could affect many organs, including the blood, heart, brain, kidneys, pancreas, and eyes. 12,13 Moreover, the severity of the infection has also been related to several laboratory variables. Prothrombin time, Creactive protein, D-dimer, procalcitonin, and fibrinogen levels have reportedly been associated with the deterioration of the disease. [14][15][16][17][18] Some of these biomarkers have helped in building prediction models to decrease mortality among critically-ill COVID-19 patients. 19,20 Other investigations have reported an association between patients' blood type and the prognosis of the infection. 21,22 This indicates the fact that mortality because of COVID-19 is different due to the different epidemiology among the affected populations. 23

| Data analysis
Data entry and analyses were conducted using SPSS v.26 (IBM, NY).
Nominal variables were presented as frequencies (n) and percentages (%). The Chi 2 test (or Fisher's exact test, as appropriate) was used for identifying differences between hospitals. The continuous variables were presented as means and standard deviations (SDs). We used a ttest or Mann-Whitney test based on the distribution of the data (normally distributed or not).
A binary logistic regression model was constructed to control any potential confounders and determine the significantly associated factors with the mortality outcome. The odds ratio and 95% confidence interval ([95% CI]) are presented. Statistical significance was set at a P-value < 0.05 for all analyses.

| Informed consent and ethical considerations
No identifying information on any patient was collected, and all collected data were exclusively used for statistical analysis. All data were kept confidential. Before commencement, the study protocol was cleared by the institutional review board and the ethics committee at King Fahad Medical City, Riyadh, Saudi Arabia.

| Baseline characteristics
We identified 76 patients that met the inclusion criteria; 38 were patients at Hospital A, and 38 were patients at Hospital B. The mean age of the included patients was 51.7 years, and 93% of the patients were male. We found no statistically significant differences among the included patients between both hospitals in terms of age (Pvalue = 0.322), gender (P-value = 0.500) or the percentage of overweight (P-value = 0.911). In contrast, we found a statically significant difference in the nationality distribution among the aforementioned two hospitals (P-value < 0.001) ( Table 1).
Only 12% of the patients reported smoking; 47% of the patients had one or more documented comorbidities. The most prevalent comorbidity was diabetes mellitus (DM), being present in 36% of the patients, followed by hypertension (32%) and ischemic heart disease (IHD) in 11%. We also found a statistically significant difference in the prevalence rates of hypertension between patients between the two hospitals (P-value = 0.048) ( Table 1).

| Patients' admission details and baseline clinical data
The mean admission body temperature of all patients was 37.7 C, whereas their mean initial respiratory rate was 26.6 breaths per minute, and the mean initial heart rate was 98.6 ± 19.3 beats per minute. The mean visual triage score was 6.7 ± 1.9, and the mean Glasgow Coma Scale was 10.2 ± 5.6. For Hospital B, the mean visual triage score was 6.3 ± 2.5, while the mean Glasgow Coma Scale was 10.8 ± 5.4. For those patients with available data, 76% of the patients were registered as an emergency, 17% were directly admitted to the ICU, and 7% were registered from the outpatient department. In the same context, the admission source was variable among the included patients; 30.3% of the patients were admitted from the emergency room, 26% were referred from another hospital, 22% were admitted from the clinic, and 21.1% were in the hospital ward. Most of the patients (76%) did not sign a "Do not resuscitate" form, while only 24% did sign it. Nevertheless, there was a statistically significant difference between Hospital B and Hospital A in terms of initial body temperature (P-value = 0.001), initial heart rate (P-value = 0.002), and registry type (P-value< 0001) (Tables 2 and 3). On admission, 79% of the included patients presented with fever, 76% with shortness of breath, 10% with a sore throat, and 75% with a cough. Regarding the cough type at presentation, 16% of the included patients presented with productive cough, and 15% presented with non-productive cough, whereas the remaining portion either did not have a cough or did not have a documented cough type. We did not find any statistically significant differences regarding fever (Pvalue = 1.000), shortness of breath (P-value = 1.000), sore throat (Pvalue = 0.711), cough (P-value = 0.791), or type of cough among the included patients (P-value = 0.250) among the included patients (Table 4).

| Comparison of patients' findings and examination results
The mean O 2 saturation at the admission was 83.9 ± 9. had bilateral crackles, 3% had rhonchi, and 1% had scattered crepitations. There was a statistically significant difference between the two hospitals in the patterns of breathing rhythm (P-value = 0.017), breathing quality (P-value = 0.029), and added sounds (Pvalue = 0.029) among the included patients (Tables 4 and 5).

| Comparison of interventions/treatments used for patients in both hospitals
The majority of the patients (93%) were admitted to the ICU at some point, and most of the patients (89%) required ventilation during their treatment course. There was no statistically significant difference between hospitals in the ICU admission (P-value = 0.644) or ventilation rates (P-value = 0.262) among the included patients. Regarding drugs administered, about two-thirds (64%) of the patients were treated with hydroxychloroquine, and most patients (74%) were treated with heparin. There was a statistically significant difference between the two hospitals in heparin usage rates (P-value < 0.001), whereas hydroxychloroquine usage rates were comparable (P-value = 0.811) ( Table 6). (OR = 0.94; 95% CI = 0.84-1.06). These reductions were not statistically significant (Table 8).

| DISCUSSION
In our study, we compared a hospital in the Saudi Western Province (Medina) to a hospital in the Saudi Eastern Province (Dammam). The COVID-related mortalities during the observed duration were similar between the two hospitals/provinces. This is consistent with the Saudi official records where the total cases in the Eastern Province were 82,072, with overall deaths of 557 (mortality rate of 0.68%). 24 In the same context, the total cases in Medina were 23,272, with overall deaths of 132 (mortality rate of 0.57%). 24 Overall, Saudi Arabia's case fatality rate is also among the lowest fatality rates in the world, ranging from 0% to 28.9%. 25 According to our results, it is consistent in different regions of Saudi Arabia, which supports that the quality of healthcare is relatively homogenous and of adequate quality.
Our results showed a relatively consistent presentation of clinical symptoms/signs among the included patients in comparing the two hospitals. Nevertheless, there were some differences in the initial presentation, including the initial body temperature, initial heart rate, breathing rhythms, breathing quality, and added sounds. Many of the previously reported MERS-CoV 26 and SARS-CoV 27 patients also showed similar comorbidities, which predisposed to increasing the risk of infection with MERS-CoV and increasing the case fatality rates. 28 Regarding clinical presentation, the predominant presentations among COVID-19 patients were low-grade high fever (mean temperature 37.7) and cough, which seems to be consistent with the initial reports from different countries. 3,12,[29][30][31] According to our results, treatments used were homogenous among the two hospitals, except for heparin use. Others have reported that many COVID-19 patients suffer from a hypercoagulability state. 32,33 To our knowledge, this is the first study to compare COVIDpatients in two Saudi hospitals in two different provinces. However, the study has some limitations. The relatively small number of included patients may affect the magnitude of differences and the statistical significance. Moreover, some patients' data were missing, which may also affect our results.

| CONCLUSION
Throughout the COVID-19 outbreak in Saudi Arabia, the Kingdom has maintained a robust healthcare system and minimized case fatalities.
we found a relatively consistent presentation of clinical symptoms/ signs among the included patients in comparing the two hospitals.

ACKNOWLEDGMENTS
We are grateful to all the staff at the local health authorities and people engaged in the COVID-19 response in Saudi Arabia. We are also particularly grateful to Dr. Joanna Gaines from the Centers for Disease Control and Prevention without whose participation and assistance this study would not have been possible.