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Readmission and Death After Initial Hospital Discharge Among Patients with COVID-19 in a Large Multihospital System

Our take —

This large retrospective cohort study from the early phase of the pandemic (March 1 to July 1, 2020) found that USA Veteran Affairs patients initially hospitalized for COVID-19 had significantly higher rates of readmission or death within 10 days after discharge compared to patients hospitalized for pneumonia or heart failure. Within 60 days after discharge, 20% of patients initially hospitalized for COVID-19 had been re-admitted and 9% had died; however, these proportions were lower than those in the comparison groups over the full time period. These results highlight a period of high risk immediately following hospital discharge in this population. However, the study population was predominantly male with a median age over 70 years, and few covariates were considered; for these reasons, results might not be generalizable to the general U.S. population.

Study design

Retrospective Cohort

Study population and setting

This retrospective cohort study investigated rates of readmission and death in the 60 days following discharge after initial hospitalization for COVID-19. The study used data from 132 hospitals in the United States Veterans Affairs (VA) health care system to identify patients who had survived hospitalizations for COVID-19 (n=1,775), including “definite” cases with a diagnosis of COVID-19 during hospitalization as well as “probable” cases diagnosed with COVID-19 during the 14 days before or 7 days after hospitalization (admitted from March 1 to June 1, 2020 and discharged from March 1 to July 1, 2020). Comparison cohorts included patients discharged alive after hospitalization for non-COVID-19-pneumonia (n=1,799) and heart failure (3,505) during the same time period. Weights on the basis of age, sex, week of discharge, length of hospitalization, and ICU use were applied from coarsened exact matching to balance comparisons between cohorts. Primary outcomes were hospital readmission, death, and the composite outcome of readmission or death after initial hospitalization with COVID-19 compared to matched comparison cohorts. Kaplan-Meier survival curves were estimated for each outcome following initial discharge.

Summary of Main Findings

The COVID-19 hospitalization cohort was predominantly male (95.1%), and self-reported race was 50.2% Black and 43.8% white. Within 60 days of discharge, 354 COVID-19 patients (19.9%) were readmitted, 162 (9.1%) died, and 479 (27.0%) were either readmitted or died. COVID-19 patients who remained alive at the end of follow-up were significantly younger than those who died (median age 70 vs. 80 years; p<0.001), but the two groups were otherwise similar. COVID-19 survivors had lower 60-day readmission or death rates than matched survivors of pneumonia (26.1% vs 31.7%; p 0.006) and heart failure (27.0% vs 37.0%; p<0.001). However, within the first 10 days after discharge, COVID-19 survivors had higher rates of readmission or death compared to matched survivors of pneumonia (13.4% vs 9.7%; p 0.01) and heart failure (13.9% vs 8.8%; p<0.001).

Study Strengths

This large multicenter cohort study utilized data from 132 VA hospitals and included a large proportion of Black patients, a demographic group disproportionately affected by COVID-19 in the United States.

Limitations

This study looked at an exclusively inpatient and primarily older male population, limiting generalizability to outpatient settings as well as to younger and non-male patients. This study took place early in the pandemic in the United States, a time with limited testing resources and standardization, which may have resulted in selection bias toward patients with severe and classic disease presentations. Because of the high case burden in hospitals during this period, criteria for discharge may have differed from other periods, potentially representing mortality and morbidity rates immediately post-discharge which would be an overestimate during periods with lower case volumes. This study could not account for hospitalizations and care sought outside the VA system, potentially underestimating COVID-19 burden of disease. This study was not randomized, and residual confounding may exist despite cohort matching. Few covariates were measured, and several omitted variables (e.g., comorbidities) may have plausibly affected observed relationships between COVID-19 discharge and outcomes.

Value added

This large cohort study is among the first to investigate COVID-19-related readmission and mortality compared to relevant comparison groups.

This review was posted on: 19 February 2021