Credible learning of hydroxychloroquine and dexamethasone effects on COVID-19 mortality outside of randomized trials

ObjectivesTo investigate the effectiveness of hydroxychloroquine and dexamethasone on coronavirus disease (COVID-19) mortality using patient data outside of randomized trials. DesignPhenotypes derived from electronic health records were analyzed using the stability-controlled quasi-experiment (SCQE) to provide a range of possible causal effects of hydroxy-chloroquine and dexamethasone on COVID-19 mortality. Setting and participantsData from 2,007 COVID-19 positive patients hospitalized at a large university hospital system over the course of 200 days and not enrolled in randomized trials were analyzed using SCQE. For hyrdoxychloroquine, we examine a high-use cohort (n=766, days 1 to 43) and a later, low-use cohort (n=548, days 44 to 82). For dexamethasone, we examine a low-use cohort (n=614, days 44 to 101) and high-use cohort (n=622, days 102 to 200). Outcome measure14-day mortality, with a secondary outcome of 28-day mortality. ResultsHydroxycholoroquine could only have been significantly (p<0.05) beneficial if baseline mortality was at least 6.4 percentage points (55%) lower among patients in the later (low-use) than the earlier (high-use) cohort. Hydroxychloroquine instead proves significantly harmful if baseline mortality rose from one cohort to the next by just 0.3 percentage points. Dexamethasone significantly reduced mortality risk if baseline mortality in the later (high-use) cohort (days 102-200) was higher than, the same as, or up to 1.5 percentage points lower than that in the earlier (low-use) cohort (days 44-101). It could only prove significantly harmful if mortality improved from one cohort to the next by 6.8 percentage points due to other causes--an assumption implying an unlikely 84% reduction in mortality due to other causes, leaving an in-hospital mortality rate of just 1.3%. ConclusionsThe assumptions required for a beneficial effect of hydroxychloroquine on 14 day mortality are difficult to sustain, while the assumptions required for hydroxychloroquine to be harmful are difficult to reject with confidence. Dexamethasone, by contrast, was beneficial under a wide range of plausible assumptions, and was only harmful if a nearly impossible assumption is met. More broadly, the SCQE reveals what inferences can be credibly supported by evidence from non-randomized uses of experimental therapies, making it a useful tool when randomized trials have not yet produced clear evidence or to provide corroborative evidence from different populations.