Original Article

Readmission Risk after COVID-19 Hospitalization: A Moderation Analysis by Vital Signs

Authors: Arkadiy Finn, MD, Joshua R. Tanzer, PhD, Atin Jindal, MD, Vijairam Selvaraj, MD, Bradley Collins, MD, Kwame Dapaah-Afriyie, MD

Abstract

Objective: Readmission to the hospital after hospitalization with coronavirus disease 2019 (COVID-19) is associated with significant morbidity and mortality. Hospital clinicians may identify the presence of a patient’s comorbid conditions, overall severity of illness, and clinical status at discharge as risk factors for readmission. Objective data are lacking to support reliance on these factors for discharge decision making. The objective of our study was to examine risk factors for readmission to the hospital after COVID-19 hospitalization and the impact of vital sign abnormalities, within 24 hours of discharge, on readmission rates.

Methods: In total, 2557 COVID-19-related hospital admissions within the Lifespan Health System, a large multicenter health system (Rhode Island), of 2230 unique patients aged 18 years and older, occurring from April 1, 2020 to December 31, 2020 were analyzed. Risk factors associated with readmission within 30 days were identified and analyzed using Cox regression. A moderation analysis by vital signs at discharge on the risk of readmission was performed.

Results: Clinical factors associated with readmissions included existing cardiovascular conditions (risk ratio 2.32, 95% confidence interval [CI] 1.10–4.90) and pulmonary disease (risk ratio 3.25, 95% CI 1.62–6.52). The absence of abnormal vital signs within 24 hours of discharge was associated with decreased 30-day readmission rates (risk ratio 0.70, 95% CI 0.52–0.94). Elevated C-reactive protein and d-dimer values and in-hospital complications including stroke, myocardial infarction, acute renal failure, and gastrointestinal bleeding were not associated with an increased risk of readmission. In moderation analysis, the presence of normal vital signs within 24 hours of discharge was associated with decreased readmission risk in patients who had primary risk factors for readmission including pulmonary disease (risk ratio 0.80, 95% CI 0.65–0.99), psychiatric disorders, and substance use (risk ratio 0.70, 95% CI 0.52–0.94).

Conclusions: Comorbid conditions, including pulmonary and cardiovascular disease, are associated with readmission risk after COVID-19 hospitalization. The normalization of vital signs within 24 hours of discharge during COVID-19 hospitalization may be an indicator of readiness for discharge and may mitigate some readmission risk conferred by comorbid conditions.
Posted in: Infectious Disease143

Full Article

Having trouble viewing the article content below? Click here to open it directly.

Images

Download Image

Download Image

Download Image

Download Image

References

1. Centers for Disease Control and Prevention. COVID data tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed September 4, 2022.
 
2. Banerjee J, Canamar CP, Voyageur C, et al. Mortality and readmission rates among patients with COVID-19 after discharge from acute care setting with supplemental oxygen. JAMA Netw Open 2021;4:e213990.
 
3. Donnelly JP, Wang XQ, Iwashyna TJ, et al. Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system. JAMA 2021;325:304–306.
 
4. Jeon WH, Seon JY, Park SY, et al. Analysis of risk factors on readmission cases of COVID-19 in the Republic of Korea: using nationwide health claims data. Int J Environ Res Public Health 2020;17:5844.
 
5. Lavery AM, Preston LE, Ko JY, et al. Characteristics of hospitalized COVID-19 patients discharged and experiencing same-hospital readmission – United States, March-August 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1695–1699.
 
6. Parra LM, Cantero M, Morrás I, et al. Hospital readmissions of discharged patients with COVID-19. Int J Gen Med 2020;13:1359–1366.
 
7. Somani SS, Richter F, Fuster V, et al. Characterization of patients who return to hospital following discharge from hospitalization for COVID-19. J Gen Intern Med 2020;35:2838–2844.
 
8. Yeo I, Baek S, Kim J, et al. Assessment of thirty-day readmission rate, timing, causes and predictors after hospitalization with COVID-19. J Intern Med 2021;290:157–165.
 
9. Ramos-Martínez A, Parra-Ramírez LM, Morrás I, et al. Frequency, risk factors, and outcomes of hospital readmissions of COVID-19 patients. Sci Rep 2021;11:13733.
 
10. Rodriguez VA, Bhave S, Chen R, et al. Development and validation of prediction models for mechanical ventilation, renal replacement therapy, and readmission in COVID-19 patients. J Am Med Inform Assoc 2021;28:1480–1488.
 
11. Gwin M, Saleki M, Lampert H, et al. Emergency department visits and readmissions after COVID-19 hospitalization: a cross-sectional analysis. Intern Emerg Med 2021;16:1715–1718.
 
12. Chopra V, Flanders SA, O’Malley M, et al. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med 2021;174:576–578.
 
13. Miller RG Jr. Survival Analysis, Vol. 66. New York: John Wiley & Sons; 2011.
 
14. Mirkin KA, Enomoto LM, Caputo GM, et al. Risk factors for 30-day readmission in patients with congestive heart failure. Heart Lung 2017;46:357–362.
 
15. Harlow LL. The Essence of Multivariate Thinking: Basic Themes and Methods, 2nd ed. London: Routledge/Taylor & Francis Group; 2014.
 
16. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020;323:2052–2059.
 
17. Loerinc LB, Scheel AM, Evans ST, et al. Discharge characteristics and care transitions of hospitalized patients with COVID-19. Healthc (Amst) 2021;9: 100512.
 
18. Atalla E, Kalligeros M, Giampaolo G, et al. Readmissions among patients with COVID-19. Int J Clin Pract 2021;75:e13700.
 
19. Verna EC, Landis C, Brown RS Jr, et al. Factors associated with readmission in the US following hospitalization with COVID-19. Clin Infect Dis 2022;74: 1713–1721.
 
20. Clark JR, Batra A, Shlobin NA, et al. Acute-care hospital reencounters in COVID-19 patients. Geroscience 2021;43:2041–2053.
 
21. Choi JJ, Contractor JH, Shaw AL, et al. COVID-19-related circumstances for hospital readmissions: a case series from 2 New York City hospitals. J Patient Saf 2021;17:264–269.
 
22. Saab FG, Chiang JN, Brook R, et al. Discharge clinical characteristics and post-discharge events in patients with severe COVID-19: a descriptive case series. J Gen Intern Med 2021;36:1017–1022.
 
23. Guarin G, Lo KB, Bhargav R, et al. Factors associated with hospital readmissions among patients with COVID-19: a single-center experience. J Med Virol 2021;93:5582–5587.
 
24. Alqahtani JS, Njoku CM, Bereznicki B, et al. Risk factors for all-cause hospital readmission following exacerbation of COPD: a systematic review and meta-analysis. Eur Respir Rev 2020;29:190166. .
 
25. Dobrzynski DM, Ndi DN, Zhu Y, et al. Hospital readmissions after laboratory-confirmed influenza hospitalization. J Infect Dis 2020;222: 583–589.
 
26. Cui Z, Merritt Z, Assa A, et al. Early and significant reduction in C-reactive protein levels after corticosteroid therapy is associated with reduced mortality in patients with COVID-19. J Hosp Med 2021;16:142–148.
 
27. Smilowitz NR, Kunichoff D, Garshick M, et al. C-reactive protein and clinical outcomes in patients with COVID-19. Eur Heart J 2021;42:2270–2279.
 
28. Pittappilly M, Sarao MS, Bambach WL, et al. Vital signs on hospital discharge and readmission rates. QJM 2019;112:275–279.
 
29. Nguyen OK, Makam AN, Clark C, et al. Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes. J Gen Intern Med 2017;32:42–48.
 
30. Memon MA, Cheah JH, Ramayah T, et al. Moderation analysis: issues and guidelines. Struct Equ Modeling 2019;3:i–xi.