key: cord-0718042-1az2dz08 authors: Qu, Guangbo; Zhen, Qi; Wang, Wenjun; Fan, Song; Wu, Qibing; Zhang, Chengyuan; Li, Bao; Liu, Gang; Yu, Yafen; Li, Yonghuai; Yong, Liang; Lu, Baojing; Ding, Zhen; Ge, Huiyao; Mao, Yiwen; Chen, Weiwei; Xu, Qiongqiong; Zhang, Ruixue; Cao, Lu; Chen, Shirui; Li, Haiwen; Zhang, Hui; Hu, Xia; Zhang, Jing; Wang, Yonglian; Zhang, Hong; Liang, Chaozhao; Sun, Liangdan; Sun, Yehuan title: Health‐related quality of life of COVID‐19 patients after discharge: A multicenter follow‐up study date: 2021-03-17 journal: J Clin Nurs DOI: 10.1111/jocn.15733 sha: 659347c82fadc11157ea036473d3a8ba6cbabf99 doc_id: 718042 cord_uid: 1az2dz08 AIMS AND OBJECTIVES: To determine the health‐related quality of life (HRQoL) of COVID‐19 patients after discharge and its predicting factors. BACKGROUND: COVID‐19 has caused a worldwide pandemic and led a huge impact on the health of human and daily life. It has been demonstrated that physical and psychological conditions of hospitalised COVID‐19 patients are impaired, but the studies focus on physical and psychological conditions of COVID‐19 patients after discharge from hospital are rare. DESIGN: A multicentre follow‐up study. METHODS: This was a multicentre follow‐up study of COVID‐19 patients who had discharged from six designated hospitals. Physical symptoms and HRQoL were surveyed at first follow‐up (the third month after discharge). The latest multiple laboratory findings were collected through medical examination records. This study was performed and reported in accordance with STROBE checklist. RESULTS: Three hundred eleven patients (57.6%) were reported with one or more physical symptoms. The scores of HRQoL of COVID‐19 patients at third month after discharge, except for the dimension of general health, were significantly lower than Chinese population norm (p < .001). Results of logistic regression showed that female (odds ratio (OR): 1.79, 95% confidence interval (CI): 1.04–3.06), older age (≥60 years) (OR: 2.44, 95% CI: 1.33–4.47) and the physical symptom after discharge (OR: 40.15, 95% CI: 9.68–166.49) were risk factors for poor physical component summary; the physical symptom after discharge (OR: 6.68, 95% CI: 4.21–10.59) was a risk factor for poor mental component summary. CONCLUSIONS: Health‐related quality of life of discharged COVID‐19 patients did not come back to normal at third month after discharge and affected by age, sex and the physical symptom after discharge. RELEVANCE TO CLINICAL PRACTICE: Healthcare workers should pay more attention to the physical and psychological rehabilitation of discharged COVID‐19 patients. Long‐term follow‐up on COVID‐19 patients after discharge is needed to determine the long‐term impact of COVID‐19. Coronavirus disease 2019 (COVID-19) is a novel pneumonia infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a member of the betacoronavirus genus. The main clinical characteristics of COVID-19 are fever, cough and shortness of breath , and a proportion of patients may accompany with new loss of taste or smell (Dawson et al., 2020) , diarrhoea, nausea, vomiting and other symptoms Kim et al., 2020; Tian et al., 2020) . Currently, COVID-19 has caused a worldwide pandemic and led a huge impact on the health of human and daily life. To date, there are more than twenty million confirmed cases and seven hundred thousand cases died with COVID-19 infection worldwide according to the reports of World Health Organization (WHO) (World Health Organization, 2020) . Previous studies have revealed some positive laboratory findings and reactivated clinical features of discharged COVID-19 patients (Zheng et al., 2020) . As reviewed by Zheng and colleagues (Zheng et al., 2020) , approximately 3.2% to 9.1% of discharged patients may experience SARS-COV-2 reactivation but without specific clinical features to distinguish them. Some clinical symptoms including fever, cough, sore throat and fatigue were also observed among discharged patients with SARS-COV-2 reactivation Zheng et al., 2020) . In addition, due to incomplete recovery of pulmonary injury, present palpitation, shortness of breath or dyspnoea may still occur after physical activity for discharged patients (Zheng et al., 2020) . Another concern is that considering the impact of coronavirus infection on the daily life and work, a considerable number of COVID-19 patients may still have psychological problems after discharge from hospital (Yuan et al., 2020) . Therefore, all mentioned above suggests that the physical and mental functions of some discharged patients do not come back to normal and at the risk of deterioration. Health-related quality of life (HRQoL) has aroused much interest in the social progress and the transformation of medical care and service systems, which refers to the impact of disease and treatment on patients' function and overall life satisfaction (Gill & Feinstein, 1994; Schipper et al., 1996) . Similar to other diseases, it has been demonstrated in several studies that COVID-19 can affect HRQoL of patients and general populations Zhang & Ma, 2020) . Physical symptoms are still observed among COVID-19 patients after discharged from hospital (Carfì et al., 2020) , which may also affect their normal life and lead to poor HRQoL. However, only few studies have reported HRQoL of patients after discharge. One previous cross-sectional study has revealed that HRQoL was poor among COVID-19 patients at the first-month follow-up and several risk factors are determined . Garrigues et al., (2020) have found that there are few differences for HRQoL between ward and ICU COVID-19 patients after discharge. Considering studies reporting physical and psychological conditions of COVID-19 patients after discharge from hospital are rare, this multicentre study was performed to investigate the physical condition and HRQoL of COVID-19 patients after discharge. Meanwhile, factors associated with poor health-related quality of life were also explored. This study was performed and reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guideline for cohort studies (Supplementary File 1). This was a multicentre follow-up study of COVID-19 patients who had been discharged from designated hospitals in Anhui Province and Hubei Province. Six designated hospitals in Anhui Province and Hubei Province for the treatment of COVID-19 were selected to recruit discharged patients with COVID-19 infection. The inclusion criteria of participants were as follows: (1) the patients were definitely diagnosed with SARS-CoV-2 infection on hospital admission (the diagnosis of SARS-CoV-2 infection was based on guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia of Chinese: positive for the 2019-nCoV by the real-time PCR test for nucleic acid in respiratory or blood samples); (2) hospitalisation for the following reasons: fever (axillary temperature was 36.7°C and above, or oral temperature was 38.0°C and above, or anal temperature or ear temperature was 38.6°C and above) and respiratory rate was more than 24 times/min or cough (at least one of shortness of breath and cough); (3) the clinical type of COVID-19 at hospital admission was mild to severe according to the Chinese management guideline for COVID-19 (Sixth edition); and (4) participants were required to meet the standard hospital discharge criteria (no fever for at least 3 days; substantial resolution of pneumonia with a CT scan, two negative SARS-CoV-2 RT-qPCR tests done at least 1 day apart on nasopharyngeal and oropharyngeal swabs, and no concurrent acute medical issues requiring transfer to another medical facility). The exclusion criteria of participants were as follows: (1) confirmed hepatitis B, C, AIDS and other viral infections; (2) women who were in pregnancy (positive pregnancy test for women of childbearing age); (3) subjects with other unsuitable factors considered by the researchers; and (4) discharged patients were unwilling to participate in this study. Five hundred eighty one discharged patients (including 511 mild or moderate COVID-19 patients and 70 severe COVID-19 patients) were invited to participate in this study and would be first informed of the purpose and benefits of this study through telephone, and after obtaining the patients' verbal consent, an electronic survey form would be given to patients to collect interest data. For younger participants (aged less than 18), the survey was conducted in the company of parents and with the consent of parents and children. Finally, a total of 540 discharged patients were included in our study ( Figure 1 ). All included patients had been discharged between 1 February 2020-8 March 2020 (the latest patient was discharged from hospitals). The study was started on 5 May 2020 and ended on 8 June 2020. This study was approved by the Research University (PJ-2020-03-19) . Written informed consent was waived by the Ethics Commission for emerging infectious diseases. Data were collected at the first follow-up hospital appointment following discharge which is routinely offered to patients at 3 months. An electronic survey form was administered to discharged COVID-19 patients to collect the information of physical symptoms and HRQoL. Physical symptoms were self-reported by patients. According to the discharge regulations of COVID-19, patients should undergo routine examination after discharge in community hospitals or grade A hospitals with inspection qualifications. Results of multiple laboratory examination were collected through medical examination records. Times from hospital discharge to laboratory examination were recorded. In our study, the collected medical laboratory examination results include SARS-CoV-2 RNA detection (positive or negative), blood routine examination (white blood cell count, haemoglobin, platelet, C-reactive protein, neutrophil-to-lymphocyte ratio), and renal and liver function (aspartate aminotransferase, alanine aminotransferase, total bilirubin, blood urea nitrogen, serum creatinine). All data were collected by the physicians who managed and took the most care of COVID-19 patients and checked by the third researchers. There were no missing data collected in our study. Health-related quality of life was assessed using the scale of MOS 36-item Short-Form Health Survey (SF-36). SF-36 is a generic widely validated scale to measure HRQoL of inpatient or discharged patients which include eight health concepts (Brazier et al., 1992) : physical function (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social function (SF), role emotion (RE) and mental health (MH). The assessed scores of each concept were ranged from 0-100, and higher scores represent better quality. In addition, eight health concepts of SF-36 can be classified into two categories: physical component summary (PCS) and mental component summary (MCS), and the poor HRQoL was defined as scores of PCS or MCS less than 50 . In our study, the overall Cronbach's alpha of this scale was 0.547. The Chinese population norm (Rui et al., 2011) was used as the comparison to determine whether the HRQoL of COVID-19 patients after discharge was poorer than general population. Continuous variables were described as median and interquartile range (IQR) or mean and standard deviation (SD). Count variables were presented as number and percentage. The HRQoL scores were compared between two groups using t tests, and Cohen's d effect size was calculated. The magnitudes of absolute Cohen's d effect size was classified into four categories: negligible (<0.2), small (0.2-0.49), moderate (0.5-0.79) and large (>0.79) (Cohen, 1988 and joint pain (24.3%). In addition, 32 patients (5.9%) presented with SARS-COV-2 reactivation, mainly within 1-2 weeks after discharge from the hospital (timeline of 32 patients with SARS-COV-2 reactivation is presented in Figure S1 ). The comparison of scores HRQoL scores among different groups is presented in Most of the researches have focused on the HRQoL of hospitalised COVID-19 patients, but few have revealed HRQoL in post-discharge COVID-19 patients. Our study comprehensively investigated the HRQoL of COVID-19 patients after discharge from hospital and also explored its risk factors. For the HRQoL of discharged COVID-19 patients, we found that except for GH dimension, scores of all other dimensions of SF-36 were significantly lower than Chinese norm, which indicated that the HRQoL of COVID-19 patients was impaired and did not come back to normal even at three months after discharge. These findings were consistent with previous studies (Santus et al., 2020; van der Sar-van der Brugge et al., 2020) . Healthcare workers need to pay attention to physical and psychological conditions at long-term recovery of COVID-19 patients. Nevertheless, the finding of our study was partly different with a follow-up study conducted by Chen, Li, et al., (2020) who found that at one month after discharge, there was no difference in PF score between COVID-19 patients and Chinese population norm, but the scores of BP, GH, VT and MH were significantly higher and scores of RP, SF and RE were significantly lower in COVID-19 patients than the Chinese population norm. Possible causes for these differences can be explained by the differences in population characteristics that our study included more older COVID-19 patients and HRQoL of COVID-19 patients was investigated at three months after discharge. Results of multivariate logistical regression indicated that HRQoL of discharged COVID-19 patients was affected by some factors, that is, female, older age (≥60 years) and physical symptoms after discharge were risk factors for poor PCS, and the physical symptom after discharge was a risk factor for poor MCS. These findings were in line with a previous follow-up study that older age and female were risk factors for poor HRQoL . As we all know, physical symptoms are closely related to poor physical function and great psychological burden (Nunes et al., 2017; Speed et al., 2017; Storm Van's Gravesande et al., 2019) ; therefore, it is not surprising that our study found the physical symptom to be a risk factor for poor HRQoL. In our study, compared with male patients, female patients presented with significant lower scores of all dimensions of SF-36, which indicated that HRQoL of female was much poorer than male. However, results of multivariate logistical regression indicated that female was a risk factor for poor PCS but not for poor MCS. A previous study has demonstrated that women had a worse PCS recovery than men because women perceived greater psychological stress (Xu et al., 2015) . Therefore, this may be why poorer PCS in women was observed in our study. However, with the outbreak of COVID-19, women have perceived a significant higher level of post-traumatic stress than men . It has been demonstrated that in general population, women are more susceptible to a series of psychological problems (such as anxiety and depression) than men during the outbreak of COVID-19 Zhou et al., 2020) . In addition, it has been proposed that differences in coping strategies and differential neural network activation between women and men may explain gender differences in mental problems (Olff et al., 2007; Schmied et al., 2015) . Therefore, women who had experienced the infection of COVID-19 appear to be more likely to develop psychological problems and have worse recovery of physical health, which suggest that appropriate psychological intervention and care should be made for this vulnerable population even after discharge. Several limitations in our study should be noted. First, multiple confounding factors (such as chronic diseases) affected the physiological function of the body have not been collected; therefore, multivariate analysis could not be adjusted the potential confounding factors. Second, HRQoL of COVID-19 patients was only investigated at 3 months after discharge, which may only reflect short-term physical and psychological recovery of the discharged patients. Long-term follow-up can provide more comprehensive information to observe changes in physical and mental health in patients. Third, the overall Cronbach's alpha of SF-36 in our study was at a low level, which may be contributed for the proportion of older patients (≥40 years old) among our study which was higher than Chinese general population, while it should be noted that Cronbach's alphas of most dimensions of SF-36 were greater than 0.70, except for SF (0.56) and MH (0.17) dimensions, which were similar to the validity and reliability that has been well verified among the Chinese population (Rui et al., 2011; Yan et al., 2011) . Fourth, because the subjects of this study were all Chinese COVID-19 patients, the conclusion can be generalised to the Chinese population, but it may be not allowed for other countries owing to population cultural difference. Finally, although this study was the follow-up design, the information of patients was collected at first time of follow-up and cross-sectional surveyed which makes it difficult to make causal inferences. In conclusion, physical symptoms were common among COVID-19 patients after discharge, which needs much attention. HRQoL of COVID-19 patients was impaired and did not come back to normal at third month after discharge. HRQoL was significantly associated with age, sex and physical symptoms after discharge. Healthcare workers should pay more attention to the physical and psychological rehabilitation of discharged COVID-19 patients, especially for female and older patients. Long-term follow-up on COVID-19 patients is needed to determine the dynamic recovery of HRQoL. All authors disclosed no conflict of interest. Validating the SF-36 Health Survey Questionnaire: New outcome measure for primary care Gemelli Against COVID-19 Post-Acute Care Study Group Predictors of health-related quality of life and influencing factors for COVID-19 patients, a follow-up at one month Epidemiological and clinical characteristics of 99 cases of 2019 Novel Coronavirus Pneumonia in Wuhan, China: A descriptive study Statistical power analysis for the behavioral sciences Loss of taste and smell as distinguishing symptoms of COVID-19 Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19 A critical appraisal of the quality of quality-of-life measurements Abdominal and testicular pain: An atypical presentation of COVID-19 Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: Gender differences matter People with suspected COVID-19 symptoms were more likely depressed and had lower health-related quality of life: the potential benefit of health literacy Fatigue and health related quality of life in children and adolescents with cancer Gender differences in posttraumatic stress disorder Health-related quality of life in Chinese people: A population-based survey of five cities in China Changes in quality of life and dyspnoea after hospitalization in COVID-19 patients discharged at home. Multidisciplinary Respiratory Medicine Quality of life studies: Definitions and conceptual issues Sex differences in coping strategies in military survival school Characterization of pain, disability, and psychological burden in Marfan syndrome Fatigue and depression predict health-related quality of life in patients with pediatric-onset multiple sclerosis Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission Immediate psychological responses and associated factors during the initial stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the general population in China Sex differences in perceived stress and early recovery in young and middle-aged patients with acute myocardial infarction Assessment of the Chinese-version SF-36 in the Chinese opiate addicts Clinical characteristics of Severe Acute Respiratory Syndrome Coronavirus 2 reactivation Correlation between immune response and self-reported depression during convalescence from COVID-19 Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: A cross-sectional study Patient follow-up after discharge after COVID-19 Pneumonia: Considerations for infectious control Prevalence and sociodemographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19 Additional supporting information may be found online in the Supporting Information section.How to cite this article: Qu G, Zhen Q, Wang W, et al.Health-related quality of life of COVID-19 patients after discharge: A multicenter follow-up study. J Clin Nurs. 2021;00:1-9. https://doi.org/10.1111/jocn.15733