ABSTRACT
Coronavirus disease 2019 (COVID-19) has had a devastating impact on older adult nursing home residents (NHR). NHRs comprise greater than one-third of COVID-19 U.S. deaths, emphasizing the importance of engaging in end-of-life discussions. At South Texas Veterans Health Care System (STVHCS), we implemented early documentation of patient’s Life-Sustaining Treatment (LST) or end-of-life goals-of-care preferences prior COVID-19 infection. We now aim to examine the association between early LST documentation (prior to COVID-19 diagnosis) and hospital admissions for COVID-19 by conducting a retrospective cohort study of Veteran NHRs at STVHCS from March 2020-January 2021. Inclusion criteria were NHRs with COVID-19 diagnosis, LST documentation, and clear timing of whether the LST documentation occurred before or after COVID-19 diagnosis. Logistic regression was used to determine the likelihood of hospitalization by whether LST was documented before or after COVID-19 diagnosis. 208 NHRs were diagnosed with COVID-19 and 160 (76.9%) had LST documentation. Of these, 148 were included in the analysis: 84 (56.8%) had a completed LST note prior to diagnosis and 64 (43.2%) after diagnosis. The hospitalization rate was 46% for those with LST prior to diagnosis compared to 78% in those with LST after diagnosis (OR = 0.24, 95% CI: 0.12-0.50, P<0.001), showing that early LST documentation was associated with 76% lower likelihood of hospitalization. Early interventions for LST documentation can reduce hospitalization in high-risk populations. These findings may have implications for reducing unnecessary hospitalizations, diminishing healthcare costs, and resolving ethical dilemmas related to potential resource allocation during a pandemic.
ABSTRACT
Older adults suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at increased risk of death and hospitalization-related complications. The coronavirus disease 2019 (COVID-19) pandemic has forced adaptations in Telehealth, allowing COVID-19 patients to be managed at home. Traditionally, Hospital in Home (HIH) patients have better clinical outcomes and lower mortality compared to similar hospitalized patients. However, effectiveness of HIH for COVID-19 older adults remains unknown. This study examines the effect of age on rates of hospital readmission and overall mortality for patients enrolled in HIH after initial COVID-19 hospital discharge. A HIH COVID-19 monitoring program was developed to facilitate earlier hospital discharge and monitoring. Retrospective data between March 2020 and January 2021 were analyzed. Of the 402 subjects (age:26-99;mean:61.8), 13 (6.1%) subjects <65 years old vs 19 (10%) subjects □65 years old were readmitted to the hospital at least once. Two (0.94%) subjects <65 years old and 12 (6.3%) subjects □65 years old died. Older adults were 1.719 times more likely to be re-hospitalized (p=0.005) and 7.153 times more likely to die (p=0.017) compared to younger adults. Age remains a significant predictor of hospital readmission and mortality in subjects previously hospitalized for COVID-19 even when followed by monitoring programs like HIH. Further studies are needed to determine the best way to reduce hospital readmission and mortality rates for older adults after initial COVID-19 hospital discharge.
ABSTRACT
BACKGROUND: The risk of severe coronavirus disease 2019 (COVID-19) varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). OBJECTIVE: We sought to examine whether deficits in IR that antedate or are induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection independently predict COVID-19 mortality. METHODS: IR levels were quantified with 2 novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n = 522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n = 13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to COVID-19 outcomes. RESULTS: IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection was associated with underrepresentation of IHG-I (21%) versus overrepresentation (77%) of IHG-II or IHG-IV, especially in males versus females (P < .01). Presentation with IHG-I was associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics were associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. CONCLUSIONS: Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19.