key: cord-0849519-rimog224
authors: Valley, Thomas S.; Schutz, Amanda; Peltan, Ithan D.; Vranas, Kelly C.; Mathews, Kusum S.; Jolley, Sarah E.; Palakshappa, Jessica A.; Hough, Catherine L.
title: Organization of outpatient care after COVID-19 hospitalization
date: 2022-01-31
journal: Chest
DOI: 10.1016/j.chest.2022.01.034
sha: ad5d578e38a56f6adb855bd600cb0a84eeeec2a1
doc_id: 849519
cord_uid: rimog224

nan

U01HL123020). The Research Electronic Data Capture data tools used for this study were supported, in part, by the National Institutes of Health/National Center for Advancing Translational Sciences UL1TR000445. Dr. Valley was supported by AHRQ R01HS028038 and NIH K23HL140165. Dr. Vranas is supported by resources from the VA Portland Health Care System. Dr. Mathews was supported by NIH K23HL130648. Dr. Hough was supported by NIH K24HL141526.

Disclaimer: This manuscript does not necessarily represent the view of the U.S. Government or the Department of Veterans Affairs.

Survivors of COVID-19 face challenges that persist after hospitalization, 1 and a growing number of health care systems are developing multidisciplinary clinics to care for patients with postacute sequelae of COVID-19 (PASC). 2 Yet, little is known about how care is delivered to patients with COVID-19 after hospital discharge. We sought to characterize post-discharge care delivery for PASC across a large network of U.S. academic and community hospitals.

We surveyed hospitals participating in the National Heart, Lung, and Blood Institute Prevention 

Of 51 eligible PETAL Network sites, 47 hospitals responded to this survey (92% response rate).

Surveys were completed by physicians (N=29), hospital administration (N=11), social workers or discharge coordinators (N=7), research staff (N=7), or other clinicians (N=5). PETAL hospitals were urban (100%), mostly public or not-for-profit (87%), teaching hospitals (81%) that were distributed nationally: Midwest (21%), Northeast (26%), South (23%), West (30%). Ten hospitals (21%) had >20% of their patients insured by Medicaid.

Of the 47 responding hospitals, 37 (79%) provided discharge information to hospitalized patients with COVID-19 that was specific to COVID-70% counseled patients on reasons to J o u r n a l P r e -p r o o f return to the hospital, 66% on isolation precautions, and 64% on reasons to call primary care.

Only 26% of hospitals provided discharge information that included potential symptoms or impairments of post-acute sequelae of COVID-19. Post-discharge contact occurred in some capacity at 30 hospitals (63%). The most common methods of contact were through clinic visits (either in-person or virtual) (43%) or telephone (38%).

Thirty-three hospitals (70%) had a post-discharge outpatient clinic designed specifically for patients with COVID-19 (i.e., PASC clinic), with 20 started prior to August 2020. Compared to hospitals with PASC clinics, hospitals without PASC clinics were more likely to be smaller, forprofit hospitals (Table) . Hospitals without PASC clinics were also more likely to be in a ZIP code with a median annual income less than $40,000 and have a higher proportion of their patients insured by Medicaid than hospitals with PASC clinics.

Nearly all hospitals with PASC clinics required a referral for a patient to be seen (n=32, 97%).

Most referrals (70%) relied on physician discretion or patient/family requests; 39% of hospitals used specific criteria for referral; and only 21% of hospitals referred all hospitalized COVID patients. First-time patients in PASC clinics often received a range of testing, such as pulmonary function testing, quality of life assessment, six-minute walk test, chest x-ray, cognitive assessment, mental health assessment, and physical function assessment (Figure) .

Most PASC clinics (73%) were distinct from their hospital's post-ICU clinic. Of the 14 hospitals that did not have a PASC clinic, only two (14%) had plans to create one.

Using a diverse network of hospitals across the U.S., this study is the first large-scale, multicenter evaluation of care delivery following hospitalization for COVID-19. Our data demonstrate substantial variation in dissemination of PASC symptoms or impairments, post-J o u r n a l P r e -p r o o f hospital follow-up, and access to PASC clinics nationally. Hospitals without PASC clinics were more likely than hospitals with PASC clinics to be smaller, for-profit, and serve higher proportions of patients insured by Medicaid, which could reflect a paucity of resources at these hospitals. However, it is important to note that while this study provides one of the broadest assessments of PASC care to date and includes a diverse mix of academic tertiary and community hospitals, the survey was administered to hospitals within the PETAL Network, which is comprised primarily of higher resourced, urban hospitals.

We identified several key areas for potential improvement in PASC care. First, despite the growing movement towards multidisciplinary PASC care, the effectiveness of these clinics remains unknown. While multidisciplinary PASC clinics could reduce care fragmentation, they could also promote low-value care through unnecessary testing or divert resources away from clinics with established benefit. It also remains unclear what testing or assessments might be of high value for patients with PASC. It will be essential to examine the impact of these clinics on patient outcomes and to identify which, if any, aspects of PASC clinics might be beneficial.

Second, there is a need to evaluate the extent to which PASC pathophysiology and management differ from sequelae of other infections or critical illnesses (i.e., post-intensive care syndrome). Third, if multidisciplinary post-COVID care is found to be beneficial, about one of three hospitals did not have a PASC clinic, which may limit access to patients. 3 

Continuing Cardiopulmonary Symptoms, Disability, and Financial Toxicity 1 Month After Hospitalization for Third-Wave COVID-19: Early Results From a US Nationwide Cohort

Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care. The Lancet Respiratory Medicine

Post-acute COVID-19 syndrome

Sixty-Day Outcomes Among Patients Hospitalized With COVID-19