Post-acute health care burden after SARS-CoV-2 infection: A retrospective cohort study of long COVID among 530,892 adults
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Abstract
Importance
The SARS-CoV-2 pandemic portends a significant increase in health care use related to post-acute COVID sequelae, but the magnitude is not known.
Objective
To assess the burden of post-acute health care use after a positive versus negative polymerase chain reaction (PCR) test for SARS-CoV-2.
Design, Setting, and Participants
Retrospective cohort study of community-dwelling adults January 1, 2020 to March 31, 2021 in Ontario, Canada, using linked population-based health data. Follow-up began 56 days after PCR testing.
Exposures
Individuals with a positive SARS-CoV-2 PCR test were matched 1:1 to individuals who tested negative based on hospitalization, test date, public health unit, sex, and a propensity score of socio-demographic and clinical characteristics.
Main Outcomes and Measures
The health care utilization rate was the number of outpatient clinical encounters, homecare encounters, emergency department visits, days hospitalized, and days in long-term care per person-year. Mean health care utilization for test-positive versus negative individuals was compared using negative binomial regression, and rates at 95 th and 99 th percentiles were compared. Outcomes were also stratified by sex.
Results
Among 530,232 unique, matched individuals, mean age was 44 years (sd 17), 51% were female, and 0.6% had received ≥1 COVID-19 vaccine dose. The mean rate of health care utilization was 11% higher in test-positive individuals (RR 1.11, 95% confidence interval [CI] 1.10-1.13). At the 95 th percentile, test-positive individuals had 2.1 (95% CI 1.5-2.6) more health care encounters per person-year, and at the 99 th percentile 71.9 (95% CI 57.6-83.2) more health care encounters per person-year. At the 95 th percentile, test-positive women had 3.8 (95% CI 2.8-4.8) more health care encounters per person-year while there was no difference for men. At the 99 th percentile, test-positive women had 76.7 (95% CI 56.3-89.6) more encounters per person-year, compared to 37.6 (95% CI 16.7-64.3) per person-year for men.
Conclusions and Relevance
Post-acute health care utilization after a positive SARS-CoV-2 PCR test is significantly higher compared to matched test-negative individuals. Given the number of infections worldwide, this translates to a tremendous increase in use of health care resources. Stakeholders can use these findings to prepare for health care demand associated with long COVID.
Key Points
Question
How does the burden of health care use ≥56 days after a positive SARS-CoV-2 polymerase chain reaction (PCR) test compare to matched individuals who tested negative?
Findings
After accounting for multiple factors, the mean burden of post-acute health care use was 11% higher among those who tested positive, with higher rates of outpatient encounters, days hospitalized, and days in long-term care. Rates of homecare use were higher for test-positive women but lower for men.
For perspective, for every day in January 2022 with 100,000 or more infections, this translates to an estimated 72,000 additional post-acute health care encounters per year for the 1% of people who experienced the most severe complications of SARS-CoV-2; among those in the top 50% of health care use, this translates to 245,000 additional health care encounters per year. This increase will occur in the context of an ongoing pandemic and, in many health care systems, a depleted workforce and backlogs of care. Unless addressed, this increase is likely to exacerbate existing health inequities.
Meaning
Given the large number of people infected, stakeholders can use these findings to plan for health care use associated with long COVID.
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SciScore for 10.1101/2022.05.06.22274782: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Limitations: Use of PCR results may misclassify infected individuals,52,53 although its relatively low sensitivity would be expected to bias results towards the null. Similarly, because cycle-time values for PCR tests were not available and viral cultures …
SciScore for 10.1101/2022.05.06.22274782: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Limitations: Use of PCR results may misclassify infected individuals,52,53 although its relatively low sensitivity would be expected to bias results towards the null. Similarly, because cycle-time values for PCR tests were not available and viral cultures were not feasible, test-positive individuals may have been recently infected but no longer infectious at the time of their testing. Follow-up beginning eight weeks after testing was chosen to balance these considerations. Using health care encounters as a measure of post-acute COVID-19 health care needs likely underestimates the true burden of long COVID, particularly as health care decreased during initial phases of the pandemic among some populations and in Ontario, in particular.30,54-56 There is no generally accepted method for weighing severity of different types of health care encounters57,58; our composite measure gives hospitalization and long-term care more weight due to their severity, although findings were robust in sensitivity analyses. Because inclusion was conditioned on PCR testing, results may not generalize to populations with significant barriers to testing. Indication for testing and occupation (e.g., health care worker) were not available, so we are unable to determine whether these factors may modify associations between SARS-CoV-2 infection and type of post-acute health care use. To address potential changes in testing indications and capacity over time, test date was included in the propensity score a...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
Results from scite Reference Check: We found no unreliable references.
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