Residual clinical damage after COVID-19: A retrospective and prospective observational cohort study

Abstract

Data on residual clinical damage after Coronavirus disease-2019 (COVID-19) are lacking. The aims of this study were to investigate whether COVID-19 leaves behind residual dysfunction, and identify patients who might benefit from post-discharge monitoring. All patients aged ≥18 years admitted to the Emergency Department (ED) for COVID-19, and evaluated at post-discharge follow-up between 7 April and 7 May, 2020, were enrolled. Primary outcome was need of follow-up, defined as the presence at follow-up of at least one among: respiratory rate (RR) >20 breaths/min, uncontrolled blood pressure (BP) requiring therapeutic change, moderate to very severe dyspnoea, malnutrition, or new-onset cognitive impairment, according to validated scores. Post-traumatic stress disorder (PTSD) served as secondary outcome. 185 patients were included. Median [interquartile range] time from hospital discharge to follow-up was 23 [20-29] days. 109 (58.9%) patients needed follow-up. At follow-up evaluation, 58 (31.3%) patients were dyspnoeic, 41 (22.2%) tachypnoeic, 10 (5.4%) malnourished, 106 (57.3%) at risk for malnutrition. Forty (21.6%) patients had uncontrolled BP requiring therapeutic change, and 47 (25.4%) new-onset cognitive impairment. PTSD was observed in 41 (22.2%) patients. At regression tree analysis, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) and body mass index (BMI) at ED presentation, and age emerged as independent predictors of the need of follow-up. Patients with PaO2/FiO2 <324 and BMI ≥33 Kg/m2 had the highest odds to require follow-up. Among hospitalised patients, age ≥63 years, or age <63 plus non-invasive ventilation or diabetes identified those with the highest probability to need follow-up. PTSD was independently predicted by female gender and hospitalisation, the latter being protective (odds ratio, OR, 4.03, 95% confidence interval, CI, 1.76 to 9.47, p 0.0011; OR 0.37, 95% CI 0.14 to 0.92, p 0.033, respectively). COVID-19 leaves behind physical and psychological dysfunctions. Follow-up programmes should be implemented for selected patients.

Fig 1. Multidisciplinary organisation and assessment measures of the COVID-19 Follow-up Outpatient Clinic at San Raffaele University Hospital.

mMRC, modified Medical Research Council. VAS, visuo-analog scale. MoCA, Montreal Cognitive Assessment. MNA, Mini Nutritional Assessment. IES-R, Impact of Event Scale-Revised. STAI-Y, State-Trait Anxiety Inventory form Y. WHIIRS, Women’s Health Initiative Insomnia Rating Scale.

Fig 2. Prevalence of the main follow-up assessment measures.

Respiratory dysfunction was defined as respiratory rate >20 breaths/min or modified Medical Council Research scale for dyspnoea ≥2. Depicted numbers indicate the absolute counts of patients in each set. One malnourished patient had uncontrolled blood pressure levels requiring a change in therapy. BP, blood pressure.

Fig 3. Regression tree analysis (RT 1) to predict the need of post-discharge follow-up among patients recovered from COVID-19.

Event frequency defines the proportion of patients needing follow-up. The prevalence of hospitalisation in the obtained groups is depicted. Age, gender, ethnicity, history of hypertension, coronary artery disease, chronic kidney disease, diabetes mellitus, body mass index (BMI), axillary body temperature, ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂), aspartate transaminase, lactic dehydrogenase, and C-reactive protein at Emergency department presentation, and hospitalisation were included in RT 1 analysis. PaO₂/FiO₂ was available for 155 patients. BMI was available for 160 patients. Pts, patients. PaO₂/FiO₂, ratio of arterial oxygen partial pressure to fractional inspired oxygen. BMI, body mass index.

Fig 4. Regression tree analysis (RT 2) to predict the need of post-discharge follow-up among hospitalised patients recovered from COVID-19.

Event frequency defines the proportion of patients needing follow-up. Age, gender, ethnicity, history of hypertension, coronary artery disease, chronic kidney disease, diabetes mellitus, administration of non-invasive ventilation, length of stay, and transfer to intensive care unit were included in RT 2 analysis. Pts, patients. NIV, non-invasive ventilation. LoS, length of stay.