Socio-economic conditions affect health-related quality of life, during recovery from acute SARS-CoV-2 infection
Authors: Benatti Simone Vasilij , Venturelli Serena , Buzzetti Roberto , Binda Francesca , Belotti Luca , Soavi Laura , Biffi Ave Maria , Spada Maria Simonetta , Casati Monica , Rizzi Marco ,   on behalf of the SURVIVING COVID study group, Alessio Maria Grazia , Ambaglio Chiara , Barbui Tiziano , Bonaffini Pietro Andrea , Bondi Emi , Camera Giorgia , Carioli Greta , Carobbio Alessandra , Cesa Simonetta , Conti Caterina , Cosentini Roberto , Crotti Giacomo , Falanga Anna , Gerevini Simonetta , Ghirardi Arianna , Giammarresi Andrea , Greco Giuseppe , Imeri Gianluca , Marchetti Marina , Marinaro Claudia , Ouabou Aicha , Pellegrini Ramona , Previtali Giulia , Quinzan Giampaolo , Rossini Alessandro , Seghezzi Michela , Sessa Maria , Severgnini Roberta , Suardi Claudia , Zanoletti Adriana , Zucchi Alberto , Zuglian Gianluca 
Published: August 2024

Abstract
Background
Recovery from acute COVID-19 may be slow and incomplete: cases of Post-Acute Sequelae of COVID (PASC) are counted in millions, worldwide. We aimed to explore if and how the pre-existing Socio-economic-status (SES) influences such recovery.

Methods
We analyzed a database of 1536 consecutive patients from the first wave of COVID-19 in Italy (February-September 2020), previously admitted to our referral hospital, and followed-up in a dedicated multidisciplinary intervention. We excluded those seen earlier than 12 weeks (the conventional limit for a possible PASC syndrome), and those reporting a serious complication from the acute phase (possibly accounting for symptoms persistence). We studied whether the exposition to disadvantaged SES (estimated through the Italian Institute of Statistics’s model – ISTAT 2017) was affecting recovery outcomes, that is: symptoms (composite endpoint, i.e. at least one among: dyspnea, fatigue, myalgia, chest pain or palpitations); Health-Related-Quality-of-Life (HRQoL, as by SF-36 scale); post-traumatic-stress-disorder (as by IES-R scale); and lung structural damage (as by impaired CO diffusion, DLCO).

Results
Eight-hundred and twenty-five patients were included in the analysis (median age 59 years; IQR: 50–69 years, 60.2% men), of which 499 (60.5%) were previously admitted to hospital and 27 (3.3%) to Intensive-Care Unit (ICU). Those still complaining of symptoms at follow-up were 337 (40.9%; 95%CI 37.5–42.2%), and 256 had a possible Post-Traumatic Stress Disorder (PTSD) (31%, 95%CI 28.7–35.1%). DLCO was reduced in 147 (19.6%, 95%CI 17.0–22.7%). In a multivariable model, disadvantaged SES was associated with a lower HRQoL, especially for items exploring physical health (Limitations in physical activities: OR = 0.65; 95%CI = 0.47 to 0.89; p = 0.008; AUC = 0.74) and Bodily pain (OR = 0.57; 95%CI = 0.40 to 0.82; p = 0.002; AUC = 0.74). We did not observe any association between SES and the other outcomes.

Conclusions
Recovery after COVID-19 appears to be independently affected by a pre-existent socio-economic disadvantage, and clinical assessment should incorporate SES and HRQoL measurements, along with symptoms. The socioeconomic determinants of SARS-CoV-2 disease are not exclusive of the acute infection: this finding deserves further research and specific interventions.