ABSTRACT
STATEMENT OF PROBLEM/QUESTION: The transition between hospital discharge and primary care follow-up is a vulnerable period for patients that can result in adverse health outcomes and preventable hospital readmissions. The COVID-19 pandemic has exacerbated this transitional period, as many patients have forgone their routine healthcare visits, lost touch with their primary care providers (PCPs), and lacked a point of contact for their health needs after leaving the hospital. DESCRIPTION OF PROGRAM/INTERVENTION: We launched a postdischarge Transitions in Care Management (TCM) clinic to serve patients discharged from NYU Langone Hospital Brooklyn, an urban safety net academic hospital that serves a racially diverse and socioeconomically vulnerable population in Southwest Brooklyn. From October 2020 to October 2021, TCM visits were offered to patients prior to discharge from the general medicine service at NYU Langone Brooklyn who did not have a primary care provider or who could not get an appointment with their PCP within 10 days of discharge. Patients were given the option of in-person visits or virtual visits. TCM visits were scheduled with residents within 2 weeks of patient discharge. Questions at the TCM visit focused on scheduled speciality appointments, any discrepancy in medications prescribed at discharge, or if the patient was connected to additional community resources. MEASURES OF SUCCESS: The primary outcome was the 30-day readmission rate for patients referred to TCM compared to all patients discharged from the general medicine unit. FINDINGS TO DATE: From October 2020 through October 2021, there were a total of 357 TCM visits out of a total 806 referrals placed (44% completion rate). There was a reduction in 30-day hospital readmission rate for patients who completed a TCM visit compared with those who were not referred (5% vs 15.9%;p < 0.001). There was also a reduction in readmission rate for those who were referred but did not complete their TCM visit compared to those who were not referred (8.4% vs. 15.9%;p < 0.001). Of the completed visits, 172 were in-person, 138 were virtual, and 47 were over the telephone. Patients were also more likely to show up to their virtual visits than their in-person visits (30% no-show rate for in-person vs. 12% no-show rate for virtual). KEY LESSONS FOR DISSEMINATION: Thirty-day hospital readmission rate was lower for patients seen as part of the resident-run TCM clinic at a safety net academic medical center. Interestingly, patients referred but who did not complete TCM visits still had a decreased readmission rate compared to those who were not referred, suggesting that there may be an inherent difference in these two patient groups. Future studies will examine the differences between these groups, and analyze the factors that influence TCM referral and visit completion. Future studies will also analyze how the medium of visit (virtual vs. in-person) and specific interventions during the TCM visits (medication reconciliation, specialty appointments, community resources) influenced patients' transition in care.
ABSTRACT
RATIONALE: Survivors of the first SARS epidemic had impaired exercise capacity and lung function remain at six months after illness.1 Due to the novel nature of SARS-CoV-2, practitioners can only extrapolate from prior coronavirus pandemics when anticipating sequelae of COVID-19. This study seeks to help draw conclusions about long-term outcome in survivors of COVID-19. METHODS: Patients over 18 with confirmed COVID-19 are prospectively enrolled to a registry which collects clinical, serologic, functional, and radiographic data at one month, three months, six months, and twelve months post recovery from acute infection, as determined by symptoms (outpatients) or hospital discharge (inpatients). Complete pulmonary function tests (PFT) and 6 minute walk distances (6MWD) are collected at each time point. RESULTS: All currently completed PFT and 6MWD data were included in analysis (PFT: 1 month, n=16;3 months, n=26;6 months, n=25;6MWD: 1 month, n=14;3 months, n= 17;6 months, n=21). Mean 6MWD was 350m at 1 month, 362m at 3 months, and 373m at 6 months. At 1 month, 56% had normal spirometry;38% had restriction and 6% had mixed obstructive/restrictive pattern. At 3 months, 50% had normal spirometry with 42% showing restriction, 4% obstruction, and 4% mixed pattern. By 6 months, 64% had normal spirometry, 24% had restriction, and 12% had obstruction. There was diffusion limitation in 50% at both 1 month and 3 months;by 6 months, this improved to 32%. At one month, subjects older than 65 had significantly lower DLCO when compared those younger than 40 (10.54 vs 24.07 ml/min/mmHg, p<0.001) and when compared those aged 40-64 (10.54 vs 18.58 ml/min/mmHg, p<0.01);this change persisted at six months (13.67 vs 20.7 ml/min/mmHg, p<0.05). When stratified by clinical illness severity, or weight, there was no significant difference seen across PFT variables. 6MWD did not show significant difference when stratified by age, weight, or illness severity. CONCLUSIONS: In survivors of COVID-19, there are persistent functional and clinical sequelae up to six months post-recovery. Functional capacity remains impaired at six months. Predominant spirometric abnormality is restriction, which improves over time. Importantly, DLCO remains low in half of the subjects at both one and three months, with some improvement by 6 months. The diffusion impairment is significantly worse in patients older than 65. More investigation is required to elucidate the etiology of ongoing diffusion limitation and correlate with ventilation/perfusion studies.