Abstract
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.
Highlights
Since the beginning of the epidemic, the lethality rate, or case-fatality rate (CFR) of COVID-19 and the differences between countries have been the subject of many questions about national pandemic response policies and patient treatment
The case-fatality rate should not be confused with the mortality rate, which is the ratio of the number of deaths to the total population, or with the morbidity rate, which is the ratio of the number of cases to the total population
In order to estimate whether possible congestion in the healthcare system influenced hospital case-fatality rate, we studied the correlations between hospitalization and hospital lethality by district over the entire period
Summary
Since the beginning of the epidemic, the lethality rate, or case-fatality rate (CFR) of COVID-19 and the differences between countries have been the subject of many questions about national pandemic response policies and patient treatment. The case-fatality rate is the ratio between the number of deaths due to the disease and the number of closed cases (i.e. recovered or dead). It is estimated by the healthcare system based on the reporting of these two values. Mortality and morbidity rates depend on the extent of disease in a population, unlike case-fatality rates [5]
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