key: cord-0290311-pnridtas
authors: Salerno, S.; Sun, Y.; Morris, E. L.; He, X.; Li, Y.; Pan, Z. P.; Han, P.; Kang, J.; Sjoding, M. W.
title: Comprehensive Evaluation of COVID-19 Patient Short- and Long-term Outcomes: Disparities in Healthcare Utilization and Post-Hospitalization Outcomes
date: 2021-09-12
journal: nan
DOI: 10.1101/2021.09.07.21263213
sha: c0a416b1f4260cadef102d758501258cbe4f533c
doc_id: 290311
cord_uid: pnridtas

Abstract Background: Understanding risk factors for short- and long-term COVID-19 outcomes have implications for current guidelines and practice. We study whether early identified risk factors for COVID-19 persist one year later and through varying disease progression trajectories. Methods: This was a retrospective study of 6,731 COVID-19 patients presenting to Michigan Medicine between March 10, 2020 and March 10, 2021. We describe disease progression trajectories from diagnosis to potential hospital admission, discharge, readmission, or death. Outcomes pertained to all patients: rate of medical encounters, hospitalization-free survival, and overall survival, and hospitalized patients: discharge versus in-hospital death and readmission. Risk factors included patient age, sex, race, body mass index, and 29 comorbidity conditions. Results: Younger, non-Black patients utilized healthcare resources at higher rates, while older, male, and Black patients had higher rates of hospitalization and mortality. Diabetes with complications, coagulopathy, fluid and electrolyte disorders, and blood loss anemia were risk factors for these outcomes. Diabetes with complications, coagulopathy, fluid and electrolyte disorders, and blood loss were associated with lower discharge and higher inpatient mortality rates. Conclusions: This study found differences in healthcare utilization and adverse COVID-19 outcomes, as well as differing risk factors for short- and long-term outcomes throughout disease progression. These findings may inform providers in emergency departments or critical care settings of treatment priorities, empower healthcare stakeholders with effective disease management strategies, and aid health policy makers in optimizing allocations of medical resources.

On March 10, 2020, the first confirmed cases of severe acute respiratory syndrome coronavirus 2 39 (SARS-CoV-2) were reported in the state of Michigan. [1] Since then, Southeast Michigan 40 quickly evolved into an endemic center in the first wave of the pandemic, characterized by 41 several densely populated urban areas, including Detroit. [2] Over the course of one year, the 42 extent of the ensuing pandemic has changed drastically. More than 600,000 individuals in this 43 country have died as a result of COVID-19,[3] with more than 21,000 from Michigan. [4, 5] The 44 country was devastated with a healthcare crisis and economic wreckage, [6, 7] with medical 45 resources depleted in endemic centers [8, 9] and roughly 20 million jobs lost nationwide. [ [20, 22] . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint 

Among 6,731 analyzable patients with a positive COVID-19 diagnosis, 947 (14%) were 155 hospitalized at or after diagnosis and 153 died (2%) during the follow-up period. Among those 156 hospitalized, 840 (89%) were discharged and 160 (17%) were subsequently readmitted. We 157 observed 134 deaths among hospitalized patients: 107 (81%) in-hospital deaths, i.e., deaths 158 before discharge from their first (index) hospitalization, 17 (12%) after their index discharge, and 159 10 (7%) after readmission; see Figure 1 . 160

On average, these 6,731 COVID-19 patients were 44 years old and majority female 161 (56%), with an over-representation of Black patients (15%) as compared to the general 162 population surrounding Michigan Medicine. There was a high proportion of patients with cardiac 163 arrhythmias (27%), hypertension (32% uncomplicated, 9% complicated), chronic pulmonary 164 disease (26%), obesity (28%), and fluid and electrolyte disorders (20%; Table 1 ). Of note, a total 165 of 539 (8%) patients did not disclose their race; Table S2 (Supplement A) shows they were, in 166 general, much younger and healthier than those who identified their race. 167 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint (Table 2) . 205

Among patients hospitalized after COVID-19 diagnosis, we modeled in-hospital death versus 207 discharge, two competing hospitalization outcomes, using the Fine-Gray subdistribution hazards 208 model ( 0.34-0.97) were associated with lower inpatient mortality rates (Table 3 ). In a sensitivity 222 analysis, we restricted our competing risks analysis to patients hospitalized directly due to 223 COVID-19 and found similar patterns of associations (Supplement D, Table S5 ). 224

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (Table  4) . 250

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted September 12, 2021. ; https://doi.org/10.1101/2021.09.07.21263213 doi: medRxiv preprint With regards to less-studied post-hospitalization outcomes, fluid and electrolyte disorders 274 and blood loss anemia were associated with higher readmission and higher post-hospitalization 275 mortality rates. While mechanisms of these associations are unknown, one potential explanation 276 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. shorter-term hospitalization outcomes, discharge and in-hospital death, we identified that older 297 age, diabetes with complications, coagulopathy, fluid and electrolyte disorders, and blood loss 298 anemia were associated with lower rates of discharge and higher rates of in-hospital death. The 299 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Lastly, we failed to detect significant associations between risk factors such as obesity 308 and renal failure, which have been studied extensively in the COVID-19 literature. While 309 obesity, being pro-inflammatory, is a well-established risk factor for worsened outcomes in 310 COVID-19 patients,[99-102] we failed to detect a statistically significant obesity effect in this 311 subset of patients. Similarly, renal involvement with COVID-19 is well-studied, though 312 multifactorial in nature.[103-106] We believe this possibly due to (1) potential collinearity with 313 more down-stream risk factors included in our models and (2) a lack of statistical power to detect 314 these effects, as the directions of several effects were consistent with previously established 315 associations with obesity and renal failure, though not statistically significant. As a sensitivity 316 check, we fit univariate models for each of the comorbidity conditions, adjusted for patient 317 demographics (age, sex, and race). These results show significant associations, marginally, for 318 these risk factors (see Supplement E). 319

First, as a small number of patients who transferred in from other institutions did not have 321 medical history data, we had to remove them from analysis, though their impacts on our results 322 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 12, 2021. ; https://doi.org/10.1101/2021.09.07.21263213 doi: medRxiv preprint there may be biases in the patient mix, affecting the generalizability to more diverse populations 324 or other geographic areas. On the other hand, these patients did offer an opportunity to study 325 COVID-19 outcomes in a local region that had been severely impacted by the pandemic. Third, 326 this was a retrospective study of an existing EMR database. As such, we are limited in our ability 327 to draw causal interpretations from these results. In addition, due to the nature of EMR data, 328 there is always the possibility for misclassification bias and/or inaccurate data entry. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint 

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