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[JAMA发表论文]:新冠肺炎患者出院后的再入院及死亡
2021年01月22日 时讯速递, 进展交流 暂无评论

Research Letter December 14, 2020

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

John P. Donnelly, Xiao Qing Wang, Theodore J. Iwashyna, et al

JAMA. Published online December 14, 2020. doi:10.1001/jama.2020.21465

Although more patients are surviving severe coronavirus disease 2019 (COVID-19), there are limited data on outcomes after initial hospitalization. We therefore measured the rate of readmission, reasons for readmission, and rate of death after hospital discharge among patients with COVID-19 in the nationwide Veterans Affairs (VA) health care system.

Methods

We identified index hospitalizations for COVID-19 among veterans at 132 VA hospitals (admitted March 1-June 1, 2020; discharged March 1-July 1, 2020) in the VA’s Corporate Data Warehouse.1 Definitions included definite hospitalizations for COVID-19, in which the patient was diagnosed during hospitalization, and probablehospitalizations, in which the patient was diagnosed during the 14 days preceding or 7 days following hospitalization.2,3

We also identified comparison cohorts of hospitalizations for non-COVID pneumonia and heart failure during the same time frame, using the Agency for Healthcare Research and Quality’s Clinical Classification Software Refined diagnosis groupings.4 We extracted demographics, intensive care unit (ICU) use, length of hospitalization, receipt of invasive mechanical ventilation, and receipt of vasopressors.5We applied weights from coarsened exact matching to balance survivors of COVID-19 and control hospitalizations on age, sex, week of discharge, length of hospitalization, and ICU use.6

We measured readmission and death to 60 days after discharge among survivors of COVID-19 hospitalizations, determined the most common readmission diagnoses, and measured use of ICU, mechanical ventilation, and vasopressors during readmission.1 We compared characteristics of COVID-19 survivors who experienced vs did not experience 60-day readmission or death using Pearson χ2 and Wilcoxon rank sum tests. We compared rates of outcomes between matched survivors of COVID-19 and control hospitalizations using Rao-Scott–corrected χ2tests. Statistical tests were 2-tailed, with P < .05 considered significant. We generated Kaplan-Meier curves for readmission or death to 60 days after the initial hospital discharge. We also estimated hazard ratios and 95% CIs for 0 to 10, 10 to 20, 20 to 40, and 40 to 60 days after discharge using piecewise Cox proportional hazards regression. Analyses were performed using SAS version 9.4 (SAS Institute Inc) and Stata MP version 15.1 (StataCorp). The study was deemed exempt by the Ann Arbor VA institutional review board.

Results

There were 2179 index hospitalizations for COVID-19, of which 678 patients (31.1%) were treated in an ICU, 279 (12.8%) were mechanically ventilated, 307 (14.1%) received vasopressors, and 1775 (81.5%) survived to discharge.

Within 60 days of discharge, 354 patients (19.9%) who survived COVID-19 hospitalization were readmitted, 162 (9.1%) died, and 479 (27.0%) were readmitted or died. Survivors with 60-day readmission or death were older, but otherwise similar to survivors without readmission or death (Table). Of those readmitted, the most common readmission diagnoses were COVID-19 (30.2%), sepsis (8.5%), pneumonia (3.1%), and heart failure (3.1%). During readmission, 22.6% were treated in intensive care, 7.1% were mechanically ventilated, and 7.9% received vasopressors. Index admissions totaled 27 496 hospital days, whereas readmissions after COVID-19 resulted in 3728 additional hospitalization days.

Of the index hospitalizations, 2156 patients had pneumonia and 4269 had heart failure, of whom 97.8% and 98.3% survived to discharge, respectively. After excluding patients who died during hospitalization or could not be matched, 1799 with pneumonia and 3505 with heart failure who survived were included in the weighted comparisons with patients with COVID-19. COVID-19 survivors had lower rates of 60-day readmission or death than matched survivors of pneumonia (26.1% vs 31.7%; P = .006) and heart failure (27.0% vs 37.0%; P < .001). However, COVID-19 survivors had higher rates of readmission or death within the first 10 days after discharge than matched survivors of pneumonia (13.4% vs 9.7%; P = .01) and heart failure (13.9% vs 8.8%; P < .001) (Figure).

Discussion

In this national cohort of VA patients, 27% of survivors of COVID-19 hospitalization were readmitted or died by 60 days after discharge, and this rate was lower than matched survivors of pneumonia or heart failure. However, rates of readmission or death were higher than pneumonia or heart failure during the first 10 days after discharge following COVID-19 hospitalization, suggesting a period of heightened risk of clinical deterioration. Study limitations include the inability to measure readmissions to non-VA hospitals and an older, male-predominant study population, which may be at higher risk of severe manifestations of COVID-19. Public health surveillance or clinical trials focused exclusively on inpatient mortality may substantially underestimate burdens of COVID-19.

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