The report is a product of the VA/HSR&D Evidence Synthesis Program.
COVID-19 Post-hospitalization Healthcare Utilization: A Living Review
Coronavirus disease-2019 (COVID-19) was declared a pandemic in March 2020. As of August 2021– prior to the emergence of the Omicron variant – more than 35 million Americans had been infected with SARS-CoV-2. Given the incomplete uptake of COVID-19 vaccinations, the emergence of SARS-CoV-2 variants, and the potential for vaccinations to wane in effectiveness, many Americans are at risk for severe illness requiring hospitalization and subsequent significant functional impairment. The risk of post-COVID functional impairment, or “long COVID,” is greater among older patients and those with comorbid health conditions.
Investigators with VA’s Evidence Synthesis Program (ESP) Center in Durham, NC conducted a living review to determine the prevalence of short-term (<3 months) and long-term (≥3 months) healthcare use among adults discharged after hospitalization for COVID-19. This update revises findings from a report published in August 2021. Investigators searched MEDLINE and EMBASE databases on September 2, 2020, and the MEDLINE search was updated on February 4, 2021. After a full-text review of 267 articles, investigators identified 19 cohort studies (132,004 patients) conducted in Europe, Asia, or the United States.
Since the publication of the original report, the number and quality of the research studies have increased. Certainty of evidence was rated as moderate to high for all outcomes except home health and home oxygen use. Since the February 4, 2021 search, surveillance methods have been used to monitor the evolving literature, identifying another systematic review protocol, two other systematic reviews, and two cohort studies that were published addressing COVID-19 hospitalization.
A living rapid review updates a systematic review, incorporating relevant new evidence as it becomes available. This review was requested by national VA operations leadership that is managing COVID-19 clinical care procedures and policies.
What’s New: Summary of Findings
The investigators concluded that while most patients hospitalized with COVID-19 were discharged home without post-hospitalization rehabilitation services or skilled nursing care, a substantial minority of adults (1 in 8) required continued care. Continued care includes discharge to skilled nursing or rehabilitation facility or home health services post-discharge. Short-term readmission rates were modest (median 5%, n=8 studies). Additional findings include:
- For patients discharged home (median 81%; n = 13 studies), home health services were commonly used (median 24%, n = 3).
- Some patients were discharged to a skilled nursing facility (median 14%, n = 7 studies).
- A small portion of patients was discharged to hospice (median 3%, n = 4 studies).
- Discharge to rehabilitation facilities was reported infrequently.
- After discharge, a median of 5% of patients (n = 8 studies; range 2% to 20%) were readmitted to the hospital and a median of 4% (n = 3; range 3% to 7%) had an Emergency Department visit.
- Surveillance results showed two systematic reviews, and neither identified any additional studies meeting our eligibility criteria.
- The surveillance cohort studies showed readmission rates of 29% and 4%.
Study heterogeneity precluded meta-analysis, and the certainty of the evidence was moderate.
Understanding how COVID-19 hospitalizations influence patients’ downstream medical use can assist health systems, including VA and rehabilitation departments, in preparing to care for these patients. These findings suggest that healthcare systems will need long-term care, home health, and rehabilitation to support patients’ needs following discharge. Further, this review indicates that health systems should plan for increased demand of post-acute care in a skilled nursing or rehabilitation facility in around 14% of patients discharged after COVID-19.
Research Gaps/Future Research
The VA healthcare system now has substantial experience with COVID-19. Therefore, VA could address critical gaps in knowledge by using its rich HSR&D investigator pool and sophisticated databases to examine a broader array of outcomes in Veterans. Although beyond the scope of this review, investigators’ estimates of post-acute care service needs could be used to project post-acute care services needed for the VA population. Operational partners also identified a need to understand if the post-hospital needs for patients with COVID-19 differed in quantity, duration, or a mix of services from matched patients hospitalized for non-COVID-19 indications.
Sharpe JA, Burke C, Gordon AM, Gierisch JM, Allen KD, Goode AP, Ballengee L, Shepherd-Banigan M, Hughes JM, Hastings SN, Van Houtven C, Goldstein KM, Cantrell S, Ear B, Williams JW Jr. COVID-19 Post-Hospitalization Health Care Utilization: A Living Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-010; 2022.
To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/covid19-post-hosp.cfm (Intranet only)
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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