Post-COVID-19 functional status six-months after hospitalization
Authors: Manuel Taboada, Agustín Cariñena, Esther Moreno, Nuria Rodríguez, María Jesús Domínguez, Ana Casal, Vanessa Riveiro, María Diaz-Vieito, Luis Valdés, Julián Álvarez, Teresa Seoane-Pillado
Journal: Journal of Infection (2020)

•Long outcomes of a large sample of hospitalized CPVID-19 patients were analyzed.•A large proportion of hospitalized COVID-19 patients had a reduced functional status six months after hospitalization.•ICU patients referred a large decrease of their functional status compared with not ICU patients six months after hospitalization.•Female sex, age, length of hospital stay, mechanical ventilation, and ICU admission were associated with limitations in everyday life . We read with interest the article by Garrigues et al.1Garrigues E. Janvier P. Kherabi Y. et al.Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19.J Infect. 2020; 81: e4-e6https://doi.org/10.1016/j.jinf.2020.08.029Abstract Full Text Full Text PDF PubMed Scopus (676) Google Scholar where they described persistent symptoms and altered quality of life 100 days after hospitalization for Coronavirus disease 2019 (COVID-19). COVID-19 was first reported on December 31, 2019. Because it has only been studied for just over eleven months, our understanding of this disease is still incomplete, particularly its sequelae and long-term outcomes. Previous studies of critically COVID-19 patients have focused their investigations on clinical characteristics during their Hospitalization admission2Zhu N. Zhang D. Wang W. et al.A novel coronavirus from patients with pneumonia in China, 2019.N Engl J Med. 2020; 382: 727-733https://doi.org/10.1056/NEJMoa2001017Crossref PubMed Scopus (18749) Google Scholar, 3Grasselli G. Zangrillo A. Zanella A. et al.Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region.Italy. JAMA. 2020; 323: 1574-1581https://doi.org/10.1001/jama.2020.5394Crossref PubMed Scopus (3866) Google Scholar, 4Taboada M. Rama P. Pita-Romero R. et al.Critically ill COVID-19 patients attended by anesthesiologists in northwestern Spain: a multicenter prospective observational study.Rev Esp Anestesiol Reanim. 2020; (S0034-9356(20)30204-8)https://doi.org/10.1016/j.redar.2020.08.004Crossref PubMed Scopus (11) Google Scholar. However, long outcomes (≥ 6 months) of hospitalized patients with COVID-19 have not still been studied. These patients are susceptible to developing reduced functional status that impact their ability to care for themselves and to perform usual activities of daily living in the months following Hospital admission5Herridge M.S. Cheung A.M. Tansey C.M. et al.Canadian critical care trials group; one-year outcomes in survivors of the acute respiratory distress syndrome.N Engl J Med. 2003; 348: 683-693https://doi.org/10.1056/NEJMoa022450Crossref PubMed Scopus (1805) Google Scholar. The aim of this study was to describe functional status and the presence of persistent dyspnea six months after hospitalization, of a prospective identified cohort of patients hospitalized by COVID-19 during the March-April outbreak. We included all adult patients who were sufficiently medically ill to require hospital admission between March 1 to April 30, 2020 with confirmed acute respiratory syndrome coronavirus (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample. We collected demographic data, and Hospital outcomes. All patients who survived Hospital admission were included to assess functional status, and persistent dyspnea (on slight exertion) using a structured interview six months after hospitalization. Functional status was assessed according to the recently described post-COVID-19 functional status scale (PCFS), which consists in an ordinal scale (six grades) for assessment of patient-relevant functional limitations6Klok F.A. Boon G.J.A.M. Barco S. et al.The post-COVID-19 functional status scale: a tool to measure functional status over time after COVID-19.Eur Respir J. 2020; (PMID: 32398306)Crossref Scopus (344) Google Scholar. Grade 0 reflects the absence of any functional limitation, grade 1: negligible limitations with persistent symptoms but this has no effect on everyday life, grade 2: limitations in everyday life, occasionally need to avoid or reduce usual activities, grade 3: limitations in everyday life and the patient is not able to perform all usual activities, grade 4: severe functional limitations requiring assistance with activities of daily living, grade D: death of a patient. Persistent dyspnea correlated with COVID-19 were also obtained. Additionally, patients were asked to retrospectively recount their functional status 1–3 months before COVID-19. These surveys were conducted by trained study investigators. The ethics committee of Galicia, Spain (code No. 2020–188) approved this study and informed consent was obtained from all patients. Clinical outcomes were monitored until November 15, 2020, the date of last follow-up. All analyses were performed using R (version 4.0.2; R Foundation for Statistical Computing) and IBM SPSS (version 26; SPSS, Inc, Chicago, IL, USA). Multivariable logistic regression analyses were used to determine factors prior to and during Hospitalization associated with low functional status at six months after hospitalization. All tests were two-sided with a significance level of p < 0.05. A total of 242 COVID-19 patients were admitted to the Hospital during the study period. The mean age was 65.9 (14.1) years, and 144 (59.5) were male. Hypertension (44.2%), hyperlipidemia (37.2%), and obesity (28.9%) were the most common comorbidities. Forty-four (18.2%) patients needed ICU admission with a median (IR) length of stay of 13 (7.25–30.50) days. Thirty-one (12.8%) patients needed mechanical ventilation and 8 (3.3%) tracheostomy. Two hundred and two patients were discharged from Hospital with a median (IR) Hospital stay of 10 (7–17) days. At six months 183 patients completed the questionnaires (32 who needed ICU and 151 who did not need ICU). Table 1 displays functional status of the study population 6 months after COVID-19. A decreased functional status measured with PCFS scale was reported in 87 (47.5%) patients. Female sex, age, length of hospital stay, mechanical ventilation, and ICU admission were associated with limitations in the functional status (grade II-IV of the PCSF). A higher incidence of ICU patients reported a decrease in their functional status compared with not ICU patients (81.3% vs 40.4%, P < 0.001). A decreased in two grades in the functional status was also reported more frequently in ICU patients (56.3% vs 6%, P < 0.001). Limitation in their everyday life (grade 2–4 in the PCSF) was referred in 56.4% of ICU patients compared with 17.9% in not ICU patients (P < 0.001) (Table 1). Sex, age, length of Hospital stay, comorbidity and need for ICU admission have been included as independent variables, and a multivariate logistic regression model were conducted. Age (OR = 2.600, 95% CI: 1.192–5.671), and length of Hospital stay (OR = 1.049, 95% CI: 1.009–1.090) was associated with higher risk of limitations in the functional status (grade II-IV of the PCSF). Dyspnea on slight exertion was reported in only 19 patients (10.4%), however ICU patients recounted more frequently dyspnea compared with not ICU patients (37.5% vs 4.6%, P < 0.001).Table 1Functional status of the study sample (No = 183).Post-COVID-19 functional status scale grade:Before COVID-19 No = 1836 months After COVID-19 No = 183P valueBefore COVID-196 months after COVID-19ICU patients No = 32Not ICU patients No = 151P valueICU patients No = 32Not ICU patients No = 151P value0: No limitations in my everyday life.155 (84.7)81 (44.3)<0.00131 (96.9)124 (82.1)0.1536 (18.8)75 (49.7)<0.0011: Negligible limitations, (still have persistent symptoms).19 (10.4)57 (31.1)1 (3.1)18 (11.9)8 (25.0)49 (32.5)2: Limitations in my everyday life, occasionally need avoid or reduce usual activities3 (1.6)27 (14.8)0 (0.0)3 (2.0)10 (31.3)17 (11.3)3. Limitations in my everyday life, and I am not able to perform all usual activities.5 (2.7)12 (6.6)0 (0.0)5 (3.3)6 (18.8)6 (4.0)4. Severe limitations. I am dependent from another person due to symptoms.1 (0.5)6 (3.3)0 (0.0)1 (0.7)2 (6.3)4 (2.6)Data are expressed as n (%) or mean (SD). Functional status was measured using the Post-Covid-19 Functional Status scale. Bold values are statistically significant. Open table in a new tab Data are expressed as n (%) or mean (SD). Functional status was measured using the Post-Covid-19 Functional Status scale. Bold values are statistically significant. This cross-sectional observational study has provided preliminary information about the functional status of hospitalized COVID-19 survivors. We found that hospitalized patients with COVID-19, a large proportion of them had diminution of the functional status 6 months after hospitalization. In a previous study with a shorter follow-up period (14–21 days), Tenforde et al.7Tenforde M.W. Kim S.S. Lindsell C.J. et al.Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network — United States, March–June 2020.MMWR Morb Mortal Wkly Rep. 2020; 69 (DOI: http://dx.doi.org/): 993-998https://doi.org/10.15585/mmwr.mm6930e1Crossref PubMed Scopus (0) Google Scholar found in a telephone survey of nonhospitalized symptomatic COVID-19 patients, that 35% of them had not returned to their usual state of health and had persistent symptoms such fatigue, cough and headache. In another study with a 60-day follow-up, Carfi et al.8Carfì A. Bernabei R. Landi F. Gemelli against COVID-19 post-acute care study group. persistent symptoms in patients after acute COVID-19.JAMA. 2020; 324: 603-605https://doi.org/10.1001/jama.2020.12603Crossref PubMed Scopus (2761) Google Scholar reported that 87% of COVID-19 patients discharged from hospital were still experiencing at least one symptom, and 44% of then had worsened their quality of life. Assessment of functional limitation is needed in COVID-19 survivors to estimate the long-term burden of this illness9Belli S. Balbi B. Prince I. et al.Low physical functioning and impaired performance of activities of daily life in COVID-19 patients who survived hospitalisation.Eur Respir J. 2020; 562002096https://doi.org/10.1183/13993003.02096-2020Crossref PubMed Scopus (48) Google Scholar, 10McCue C. Cowan R. Quasim T. et al.Long term outcomes of critically ill COVID-19 pneumonia patients: early learning.Intensive Care Med. 2020; : 1-2https://doi.org/10.1007/s00134-020-06313-xCrossref Scopus (23) Google Scholar. Prospective longitudinal studies measuring objective parameters such as pulmonary function testing, 6-min walk test, quality of life, and detection of depression, anxiety and post-traumatic stress disorder will provide more informative data to understanding of the overall long-term outcomes of SARS-CoV-2 infection. A limitation of the study is that present study only included patients admitted of one hospital. Thus, the results may not reflect the experience and results of hospitalized survivors in hospitals in other regions. Regardless, these preliminary results are shared to inform long-term functional of COVID-19 patients who needed Hospital admission. The authors declare the absence of conflict of interests. At six months, a large proportion of COVID-19 patients who needed Hospital admission had reduced functional status. This decline in functional status was greater among patients who needed ICU admission compared with patients who did not. Statement: No funding provided.