Study Suggests Inpatient Mortality Underestimates the Health Burden of COVID-19 Hospitalizations in Veterans

BACKGROUND:
While more patients are surviving COVID-19, there are limited data on outcomes after their initial hospitalization. This study sought to measure the rate of readmission, reasons for readmission, and rate of death after hospital discharge among Veterans with COVID-19 who used VA healthcare. Using VA data, investigators identified 2,179 Veterans hospitalized with COVID-19 at one of 132 VA hospitals between March 1 and June 1, 2020 – who had been discharged between March 1 and July 1, 2020. They measured readmission and death to 60 days post-discharge among survivors of COVID-19 hospitalization and determined the most common readmission diagnoses. Investigators also identified comparison cohorts of VA hospitalizations for non-COVID pneumonia (n=1,799) or heart failure (n=3,505) during the same timeframe and compared outcomes between these matched survivors of COVID-19 and Veterans who had been hospitalized for pneumonia or heart failure.

FINDINGS:

• In this national cohort of VA patients, 27% of Veterans who survived COVID-19 hospitalization were readmitted or died by 60 days post-discharge, and this rate was lower than matched survivors of pneumonia (26% vs. 32%) or heart failure (27% vs. 37%).
• Rates of readmission or death were higher than matched pneumonia or heart failure survivors during the first 10 days after discharge following COVID-19 hospitalization, suggesting a period of heightened risk for clinical deterioration: pneumonia (13% vs. 10%) and heart failure (14% vs. 9%).
• COVID-19 survivors with 60-day readmission or death were older but otherwise similar to survivors without readmission or death.
• Of Veterans hospitalized with COVID-19, 678 (31%) were treated in an ICU, 279 (13%) received mechanical ventilation, 307 (14%) received vasopressors, and 1,775 (82%) survived to discharge.

IMPLICATIONS:

• Public health surveillance or clinical trials focused exclusively on inpatient mortality may substantially under-estimate the health burdens of COVID-19 following hospital discharge.
  NOTE: Although the current VA COVID mortality definition – all deaths within 30 days of initial COVID-positive test – is not limited to inpatient mortality, these results suggest that additional deaths occur beyond this time window.
• A substantial number of Veterans were re-hospitalized or died post-hospitalization for COVID-19 and other common medical illnesses, suggesting the need for post-discharge care focused on assessing for an ongoing trajectory of recovery, identifying and mitigating preventable readmissions, and ensuring goal-concordant care.

LIMITATIONS:

• Investigators were unable to measure readmissions to non-VA hospitals.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (IIR 17-045). Drs. Iwashyna and Prescott are with HSR&D’s Center for Clinical Management Research (CCMR) in Ann Arbor, MI.

Donnelly J, Wang XQ, Iwashyna T, and Prescott H. Readmission and Death after Initial Hospital Discharge among Patients with COVID-19 in a Large Multi-Hospital System. JAMA. December 14, 2020; online ahead of print.