Assessing the Prevalence of Anemia Post-COVID-19 Infection in Adult Members of a Southeastern U.S. Integrated Healthcare System (preprint)

Background COVID-19 may cause or worsen anemia, leading to fatigue, lower quality of life, increased risk of comorbidities, and significantly associated with worse outcomes in patients hospitalized with COVID-19. Little is known among a community-based population. We aimed to investigate the incidence and risk factors of anemia post-COVID diagnosis in a community-based population. Methods We identified all adult members of KPGA with a confirmed diagnosis of COVID-19 between January 2020 and March 2022 and followed through March 2023. Anemia was defined using hemoglobin (Hgb) labs 180-days (±30-days) and 365-days (±30-days) after COVID-19 diagnosis and sex-specific thresholds. Potential risk factors included demographics and clinical characteristics (defined by diagnosis codes) at the time of COVID-19 diagnosis. Hospitalization with COVID-19 was used as a marker of COVID-19 severity. Logistic regression among individuals not diagnosed with anemia pre-COVID investigated the association between each risk factor and anemia 180- and 365-days post-COVID-19 infection. We stratified fully adjusted model by hospitalization with COVID-19 to assess effect modification. Results We included 3,450 and 3,043 individuals who met the inclusion criteria and had Hgb results available 180- and 365- days post-COVID-19 diagnosis. One-third of our population had anemia 180-days (n=1,100, 32.17%) and 365-days (n=1,007, 33.09%) post-COVID-19, with approximately 11% of the cohort being newly diagnosed cases of anemia. In the fully adjusted models females (vs. males) (OR=1.71, 95% CI: 1.42, 2.06), Black or African American individuals (vs. non-Black individuals) (OR=2.34, 95% CI: 1.98, 2.76), adults diagnosed with kidney disease (OR=1.79, 95% CI: 1.42, 2.25) or diabetes  (OR=1.26, 95% CI: 1.12, 1.64), and adults hospitalized with COVID-19 (OR=1.43, 95% CI: 1.15, 1.78) were more likely to be diagnosed with anemia 365-days after COVID-19 diagnosis. Analyses stratified by hospitalization status showed a possible effect modification between hospitalization status and post-COVID-19 anemia. Discussion Our study showed that one in three people in a community-based population have anemia 180-days and 365-days after their first COVID-19 diagnosis. Anemia can cause fatigue, a lingering symptom of COVID-19 infection. Though more research is needed, ongoing surveillance of COVID-19 patients for anemia may be an important component of management of long COVID-19.

Researching COVID to enhance recovery (RECOVER) adult study protocol: Rationale, objectives and design (preprint)

Importance: SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. Methods: RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged [≥]18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms. Discussion: RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options.

Associations of Telemedicine vs. In-Person Ambulatory Care Visits on Cancellation Rates and 30-Day Follow-Up Hospitalizations and Emergency Department Visits (preprint)

Importance Studies have shown that telemedicine use in specific conditions can promote continuity of care, decreases healthcare costs, and can potentially improve clinical outcomes. The COVID-19 pandemic forced many healthcare systems to expand access for patients using telemedicine, but little is known about cancellation frequencies in telemedicine vs. in-person appointments and its impact on clinical outcomes. Objective Compare ambulatory clinic cancellation rates, 30-day inpatient hospitalizations rates, and 30-day emergency department visit rates between in-person and video telemedicine appointments, and examine differences in cancellation rates by age, race/ethnicity, gender, and insurance. Design A retrospective cohort study. Setting The largest academic healthcare system in the state of Georgia with ambulatory clinics in urban, suburban and rural settings. Participants Adults scheduled for an ambulatory clinic appointment from June 2020 to December 2020 were included. Each appointment was identified as either a video telemedicine or in-person clinic appointment. Demographics including age, race, ethnicity, gender, primary insurance, and comorbidities were extracted from the electronic medical record. Main Outcomes and Measures The primary process outcome was ambulatory clinic cancellation rates. The primary clinical outcomes were 30-day hospitalization rates and 30-day emergency department visit rates. Multivariable logistic regression was used to assess differences in the clinical outcomes between appointment types. Results A total of 1,652,623 ambulatory clinic appointments were scheduled during the study period. Ambulatory appointment cancellations rates were significantly lower among telemedicine appointments compared to in-person appointments (20.5% vs. 31.0%, p Conclusions and Relevance Our findings suggest that there are fewer barriers to attending an ambulatory care visit via telemedicine relative than in-person. Moreover, using telemedicine was not associated with any more frequent adverse clinical events compared with in-person visits.