Abstract
Objectives: To describe the clinical characteristics and possible risk factors associated with re-hospitalization within 30 days of discharge among hospitalized adult patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
Methods: This is a retrospective cohort study conducted at King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia over the period between March to November 2020. The study was conducted over 237 patients who had confirmed SARS-CoV-2 and fulfilled the study inclusion criteria (at least 14 years old, with subsequently discharged alive from the hospital) were included.
Results: The commonest presenting symptoms were cough, fever, and dyspnea. The most frequent reported comorbid diseases were diabetes mellitus and hypertension. Half of cases were regarded as severe cases whereas 14.8% were critical cases. The rate of readmission was 5.9%. Older patients were more likely to be readmitted compared to younger patients. Regarding clinical characteristics, critically ill patients were more likely to be readmitted than less severe cases. Patients with unilateral lung shadow in chest x-ray, and those with positive history of Intensive care unit (ICU) admission were more likely to be readmitted compared to their peers. Regarding medical history, the only factor significantly associated with readmission were history of cerebrovascular accident (CVA), as 22.2% of those with CVA history compared to only 1.5% of those without CVA history were more likely to be readmitted. Among laboratory findings, high lymphocytic count (>3 per microliter) was significantly associate with likelihood for readmission.
Conclusion: Readmission rate or patients hospitalization initially for Covid-19 was comparable to rates reported by most of other similar international studies. Further longitudinal larger multicentric study is warranted to have clearer image of the situation.
Since the first cases were reported in December 2019, infection with sever acute respiratory syndrome (SARS)-CoV-2 has become a worldwide pandemic.1,2 Covid-19, the illness caused by SARS-CoV-2 is becoming a concern for health care systems globally.3,4 Symptoms of SARS-CoV-2 infection are diverse, range from asymptomatic disease to life-threatening complications, including acute respiratory distress syndrome, multisystem failure,and ultimately, death. Older patients and those with preexisting respiratory or cardiovascular conditions are more susceptible to suffer of severe complications.5-7 Few studies have investigated discharge patterns and hospital readmissions among large groups of patients after an initial COVID-19 hospitalization.8,11 In our setting, it was noticed that some patients required a second emergency room visit and re-hospitalization after the initial clinical improvement and hospital discharge. Yet, little is known about risk factors associated with re-hospitalization for those patients. Therefore, determining the overall rate of early representation at multiple time points and identification of possible risk factors associated with re-hospitalization within 30 days post the initial encounter is needed to inform clinical practice, discharge decisions, and public health priorities, such as health care resource planning. Therefore, the aim of this study was to describe the clinical characteristics of patients who were re-hospitalized during the 30 days of discharge among hospitalized adult patients with confirmed SARS-CoV-2 infection. Moreover, we aimed to assess the possible risk factors associated with re-hospitalization.
Methods
This is a retrospective cohort study among adult patients admitted to a tertiary care King Salman Armed Forces Hospital (KSAFH), Tabuk, Kingdom of Saudi Arabia between March and November, 2020 with confirmed SARS-CoV-2 as evidenced by positive polymerase chain reaction (PCR) test who fulfilled the study inclusion criteria (at least 14 years old, with subsequently discharged alive from the hospital). Patients with laboratory-confirmed SARS-CoV-2 who are not admitted to the hospital and those less than 14 years old were excluded. Data pertain to the study were collected from KSAFH medical records, medical files of 237 SARS-CoV-2 positive patients who fulfilled the inclusion criteria. Variables were chosen for this analysis based on a combination of their prevalence per patient across the dataset, relevance to SARS-CoV-2 based on previous literature and empirical evidence, and the goals of this study.
These features included demographic data, key vitals, date of positive SARS-CoV-2, severity of illness, co-morbidities, laboratory measurements, radiographic findings, medications, period of hospital stay during the initial hospitalization, type and timeline of complication during subsequent hospitalizations procedures during hospitalization (including intubation and non-invasive O2 [oxygen] support), intensive care unit (ICU) course and the outcome (improved, died or readmitted). Microsoft Excel was used for data entry, cleaning, and coding while Statistical Package for the Social Science (SPSS) version 26 was used for data analysis. Frequency and percent were used for description of the categorical variables and presented in forms of tables and graphs. Chi square test, and Fisher exact test were used to assess the difference between patients of different characteristics considering the readmission rate. All statements were considered significant when p-value is less than 0.05. Permission was obtained from research ethics committee of KSAFH, Tabuk to grant approval to conduct the study.
Results
The study included 237 patients admitted with confirmed Covid-19 infection. Table 1 summarizes their demographic and personal characteristics. Males represented 58.6% of them. Almost two-thirds (64.1%) aged 64 years or less. Obese patients represented 42.3% of them. Prevalence of current smoking and pregnancy was reported among 2.6% of the total and 8.2% of females, respectively. Duration of symptoms till presentation to emergency room (ER) was 3 days or less among almost half of patients (49.7%). The commonest presenting symptoms were cough (74.6%), fever (72.9%), and dyspnea (64.8%). Regarding vital signs, maximum temperature ≥37.7c was reported by 46.4% of patients and oxygen saturation <93% was observed among 64.7% of patients. The most frequent reported comorbid diseases were diabetes mellitus (52.4%) and hypertension (48.9%). Half of cases were regarded as severe cases whereas 14.8% were critical cases (Table 1). Results of laboratory investigations are summarized in a categorized manner (Table 2). High D-dimer level (>0.5 g/L) was reported among 70.3% of patients while platelets count <150,000 per microliter was observed among 21.1% of them. Unilateral and bilateral lung shadows were present in chest x-rays of 19.2% and 58.1% of patients, respectively while normal chest x-rays were presented in 22.6 % of the patients. Admission to ICU was reported among 18% of the involved patients and positive blood or sputum cultures were reported among 4.3% and 5% of patients admitted for Covid-19. Out of 237 patients admitted throughout the period March-November 2020, 14 patients were readmitted (5.9%) (Figure 1). Older patients (≥65 years) were more likely to be readmitted compared to younger patients (11.8% vs. 2.6%), p=0.006. Regarding clinical characteristics, critically ill patients were more likely to be readmitted than less severe cases, p=0.031. Patients with unilateral lung shadow in chest x-ray (p=0.004), and those with positive history of ICU admission (p=0.006) were more likely to be readmitted compared to their peers (Table 4). Regarding medical history, the only factor significantly associated with readmission were history of cerebrovascular accident (CVA), as 22.2% of those with CVA history compared to only 1.5%% of those without CVA history were more likely to be readmitted, p=0.035 (Table 5). Among laboratory findings, high lymphocytic count (>3 per microliter) was significantly associated with likelihood for readmission, p=0.001 (Table 6).
- Rate of readmission among patients admitted for COVID-19 at King Salman Armed Forces Hospital, Tabuk (March-November 2020).
- Demographic, personal, and clinical characteristics of patients admitted for Covid-19 at King Salman Armed Forces Hospital, Tabuk (March-November, 2020) (N=237).
-Results of laboratory investigations of patients admitted for Covid-19 at King Salman Armed Forces Hospital, Tabuk (March-November 2020) (N=237).
- Demographic and personal factors associated with readmission of COVID-19 cases after hospital discharge (N=237).
- Clinical factors associated with readmission of COVID-19 cases after hospital discharge (N=237).
- Medical history associated with readmission of COVID-19 cases after hospital discharge (N=237).
- Laboratory findings associated with readmission of COVID-19 cases after hospital discharge (N=237).
Discussion
Some patients who were hospitalized and discharged for COVID-19 are readmitted to the hospital for further hospitalization because of some risk factors. In the current study we aimed estimate the rate of re-hospitalization of patients with COVID-19 as well as to identify potential risk factors for that. Initial hospitalization of Covid-19 cases is greatly influenced by many factors including the quality of care, the capacity of the medical system, and availability of hospital beds in the pandemic period.12,13 Readmission, is influenced beside patients` demographic, and clinical factors by the quality of post- discharge care discharge care.8,14 Rate of readmission in the present study was 5.9%. Higher rate was reported by others in Turkey12 (7.1%) and Unites States (13.3% and 20%).15,16 Different rate was also reported from the United States (6.7%) 30 days after discharge and Spain (4.4%).10,11,17 However, lower rate was observed in South Korea (4.3%) It seems that the rate of readmission was affected by the duration between discharge and re-discharge. In the present study, we did not specify this duration Among studied demographic factors, in the present study, older patients(≥65 years) were more likely to be readmitted compared to younger patients. The same has been confirmed instudies carried out in South Korea,10 China,18,19 and United States.20 This observed higher rate of readmission among the United States (New York City) older population in different studies, including the present one could be explained by the fact that with aging, there is reduction in the response of immune system to viral infection, so it lasts longer in the body of elderly, causing returning of symptoms or positive PCR which might cause readmission.21,23
In the present study, no gender difference was reported between patients readmitted and those not re-admitted after initial hospitalization. Some others reported that males were more likely than females to be readmitted.8,10,17,18 It should be taken into consideration the small sample size in the present study as the total number of readmitted patients was 14, so despite the rate of males who re-admitted was higher than that of females, this did not reach a statistically significant level. The higher rate of readmission among men compared to women could be attributed to the more active immune response to the coronavirus in women compared to men, moreover the virus remain in the women’s bodies for a shorter.24,25 Additionally, the prevalence of chronic illnesses and risk behaviors time. such as smoking, in general, are higher in men than women, which may have contributed to the adverse impacts of the coronavirus.26 Among studied comorbid chronic diseases, only cerebrovascular accidents were associated with likelihood of readmission in this study. Studies from South Korea27,28 reported that Covid-19 patients with underlying chronic diseases were more likely to be readmitted. Also, in Switzerland, patients with coronary artery disease, atrial fibrillation, and aortic stenosis were more likely to be readmitted while in USA, the likelihood of readmission was higher in patients with chronic diseases.8,29 In Spain and China hypertensive patients, chronic obstructive pulmonary disease and pulmonary fibrosis were more likely to be readmitted.30,31
In the current study, patients with history of ICU admission during initial hospitalization were more likely to be readmitted. This was confirmed by the results of Cosdon (2021) who observed admission to the ICU or mechanical ventilation were significantly associated with being re-admitted.15
Patients with high lymphocytic count in the present study had greater risk for readmission compared to those with normal lymphocytic count while other laboratory findings were not associated with readmission. In another study, elevated AST or low albumin levels were linked to readmission.15 Nematshahi et al32 indicated that high creatinine level during initial hospitalization increased the probability of readmission.In accordance with others studies,10,32,33 having shadows in chest x-ray was a determinant for re-admission of cases in the current study, which indicates the development of pneumonia. Therefore, it has been documented that chest imaging is a propriate tool for managing patients with COVID-19 after initial discharge.34,35
Study limitations
The study aim is to investigate the rate and predictors of readmission after initial hospitalization among Covid-19 patients in Saudi Arabia. However, some limitations should be mentioned. First of all, the study was carried out in only one healthcare facility which affects the ability to generalize the results over population in other healthcare facilities in Saudi Arabia or even in Tabuk. Second, its design as a retrospective cohort study depending for getting information on the accuracy of medical records is considered another limitation of the study. Finally, our results might be underpowered to detect a significant associations, because the relatively small sample size as only 14 patients were readmitted, so we could not apply multivariate logistic regression analysis to control for the confounders among significant risk factors in univariate analysis. Therefore, caution is warranted in interpreting our results.
In conclusion, readmission rate of patients hospitalized initially for Covid-19 was comparable to rates reported by most of other similar international studies. Older patients, those with history of CVA, high level of lymphocytic county, admitted to ICU, and with lung shadow in chest x-ray were more likely to be readmitted. Therefore, the results of the current study will help in identifying the most vulnerable patients that will help in providing those population with information of the possible being readmitted because of some preventable habits. Further longitudinal larger multicentric study is warranted to have clearer image of the situation.
Acknowledgment
The authors gratefully acknowledge Scribendi (www.scribendi.com) for the English language editing.
Footnotes
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
- Received October 2, 2022.
- Accepted April 17, 2023.
- Copyright: © Saudi Medical Journal
This is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work.
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