Comorbidities Tied to Severe Illness Risk in COVID-19 Patients

(Reuters Health) – Certain COVID-19 patients discharged home from the emergency department may have an increased risk for severe illness, even when they initially appear to be clinically stable, a recent study suggests.

Researchers examined data on 923 patients who were discharged from the emergency department (ED) after testing positive for COVID-19 from March to August 2020 at one U.S. healthcare system. Within two weeks, a total of 107 patients (11.6%) returned to the hospital with illness severity that warranted admission.

Among the 788 patients with complete data on any comorbidities or medical risk factors, researchers found a significantly increased risk that patients would return and be hospitalized when they had hypertension (adjusted odds ratio 1.92); diabetes mellitus (aOR 2.20); a history of chronic obstructive pulmonary disorder or asthma (aOR 2.21); or fever higher than 100.4 degrees Fahrenheit (aOR 2.89).

Patients with any one of these four conditions had a 2.06-fold greater risk of hospitalization within two weeks in multivariate analysis adjusting for other comorbidities. With at least two of these conditions, patients had a 6.68-fold greater risk.

“These clinical features signal the type of patient who is more likely to become very sick and require hospitalization at some point, despite initially appearing well enough to recover from COVID-19 at home,” said lead study author Dr. Neal Yuan, a cardiology fellow in the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles.

“It is not yet entirely clear if these are factors that cause more severe illness to develop or are signs of underlying processes that make patients more susceptible to worse outcomes,” Dr. Yuan said by email. “It is possible that it is a bit of both.”

For patients who did return to the hospital after being discharged home, the median length of stay was 5.30 days, with 28 patients admitted to intensive care and 11 receiving intubation. Patients with hypertension, diabetes, lung disorders or fever had a statistically-significantly longer median length of stay of 5.92 days but similar chances of ICU admission or intubation.

Results from the early months of the pandemic in the U.S. may not reflect current patient outcomes, the study team notes in Emergency Medicine Journal. Another limitation is that results from this single-center study in a major metropolitan area may not reflect what would occur elsewhere.

“At the current time, relatively few hospitals are suffering from severe overcrowding from COVID-19, so presently it is not likely that many patients are being discharged home due to lack of beds,” said Dr. Leora Horwitz, director of the Center for Healthcare Innovation and Delivery Science at New York University Langone Health in New York City.

“That may not have been the case in certain communities at the peak of their surges,” Dr. Horwitz, who wasn’t involved in the study, said by email.

However, the study results underscore that the decision to admit or discharge a patient who tests positive for COVID-19 in the emergency department should be dependent on individual patient characteristics such as the presence or severity of any comorbidities, Dr. Horwitz said.

When clinicians do consider discharge to home, they may be able to provide home oxygen monitory and have patients use portable pulse oximeters and also treat patients with oxygen at home with monitoring via a visiting nurse service, Dr. Horwitz said.

Before discharge home, however, clinicians should assess what level of social support and access to health services patients would have outside the hospital, Dr. Horwitz added.

“It is very hard to be home alone and sick, especially if older,” Dr. Horwitz said. “Similarly, if someone doesn’t have a close connection to a primary care doctor or other outpatient doctor that can follow symptoms and oxygen levels, it is difficult to treat them safely at home.”

SOURCE: Emergency Medicine Journal, online February 18, 2021.

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