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Infectious Diseases

Health Care Utilization in the 6 Months Following SARS-CoV-2 Infection

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Network Open

Published Online: August 12, 2022

Original Investigation

Article Information and Disclosures

Sara Y. Tartof, PhD, MPH^1,2;

Deborah E. Malden, DPhil, MSc^1,3;

In-Lu Amy Liu, MS¹;

Lina S. Sy, MPH¹;

Bruno J. Lewin, MD, DTMH¹;

Joshua T. B. Williams, MD⁴;

Simon J. Hambidge, MD, PhD⁴;

Jonathan D. Alpern, MD⁵;

Matthew F. Daley, PhD⁶;

Jennifer C. Nelson, PhD⁷;

David McClure, PhD⁸;

Ousseny Zerbo, PhD⁹;

Michelle L. Henninger, PhD¹⁰;

Candace Fuller, PhD¹¹;

Eric Weintraub, MPH¹²;

Sharon Saydah, PhD¹³;

Lei Qian, PhD¹

Author Affiliations

¹Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
²Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
³Centers for Disease Control and Prevention, Epidemic Intelligence Service, Atlanta, Georgia
⁴Denver Health, Office of Research Ambulatory Care Services, Denver, Colorado
⁵HealthPartners Institute, Bloomington
⁶Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado
⁷Kaiser Permanente Washington Health Research Institute, Seattle
⁸Marshfield Clinic Research Institute, Marshfield, Wisconsin
⁹Department of Research, Kaiser Permanente Northern California, Oakland
¹⁰Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon
¹¹Harvard Pilgrim Health Care Institute, Boston, Massachusetts
¹²Centers for Disease Control and Prevention, Immunization Safety Office, Atlanta, Georgia
¹³Division of Viral Diseases, Respiratory Viruses Branch, Centers for Disease Control and Prevention, Atlanta, Georgia

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Key Points

Question Is SARS-CoV-2 associated with health care utilization 6 months after the acute stage of infection?

Findings In this cohort study of 127 859 patients with positive SARS-CoV-2 test results matched to 127 859 patients with negative SARS-CoV-2 test results, health care utilization was elevated in patients with positive SARS-CoV-2 results 6 months after the acute infection. Other than COVID-19 and infectious disease sequelae, the most notable post–COVID-19 conditions associated with elevated health care utilization over 6 months included alopecia (hair loss), bronchitis, pulmonary embolism or deep vein thrombosis, and dyspnea.

Meaning These findings suggest that health care systems should consider long-term strategic resource allocation in response to the expected elevated health care utilization experienced by patients with SARS-CoV-2 infection for at least 6 months following the acute stage of infection.

Abstract

Importance After SARS-CoV-2 infection, many patients present with persistent symptoms for at least 6 months, collectively termed post-COVID conditions (PCC). However, the impact of PCC on health care utilization has not been well described.

Objectives To estimate COVID-19–associated excess health care utilization following acute SARS-CoV-2 infection and describe utilization for select PCCs among patients who had positive SARS-CoV-2 test results (including reverse transcription–polymerase chain reaction and antigen tests) compared with control patients whose results were negative.

Design, Setting, and Participants This matched retrospective cohort study included patients of all ages from 8 large integrated health care systems across the United States who completed a SARS-CoV-2 diagnostic test during March 1 to November 1, 2020. Patients were matched on age, sex, race and ethnicity, site, and date of SARS-CoV-2 test and were followed-up for 6 months. Data were analyzed from March 18, 2021, to June 8, 2022.

Exposure SARS-CoV-2 infection.

Main Outcomes and Measures Ratios of rate ratios (RRRs) for COVID-19-associated health care utilization were calculated with a difference-in-difference analysis using Poisson regression models. RRRs were estimated overall, by health care setting, by select population characteristics, and by 44 PCCs. COVID-19–associated excess health care utilization was estimated by health care setting.

Results The final matched cohort included 127 859 patients with test results positive for SARS-CoV-2 and 127 859 patients with test results negative for SARS-CoV-2. The mean (SD) age of the study population was 41.2 (18.6) years, 68 696 patients in each group (53.7%) were female, and each group included 66 211 Hispanic patients (51.8%), 9122 non-Hispanic Asian patients (7.1%), 7983 non-Hispanic Black patients (6.2%), and 34 326 non-Hispanic White patients (26.9%). Overall, SARS-CoV-2 infection was associated with a 4% increase in health care utilization over 6 months (RRR, 1.04 [95% CI, 1.03-1.05]), predominantly for virtual encounters (RRR, 1.14 [95% CI, 1.12-1.16]), followed by emergency department visits (RRR, 1.08 [95% CI, 1.04-1.12]). COVID-19–associated utilization for 18 PCCs remained elevated 6 months from the acute stage of infection, with the largest increase in COVID-19–associated utilization observed for infectious disease sequelae (RRR, 86.00 [95% CI, 5.07-1458.33]), COVID-19 (RRR, 19.47 [95% CI, 10.47-36.22]), alopecia (RRR, 2.52 [95% CI, 2.17-2.92]), bronchitis (RRR, 1.85 [95% CI, 1.62-2.12]), pulmonary embolism or deep vein thrombosis (RRR, 1.74 [95% CI, 1.36-2.23]), and dyspnea (RRR, 1.73 [95% CI, 1.61-1.86]). In total, COVID-19-associated excess health care utilization amounted to an estimated 27 217 additional medical encounters over 6 months (212.9 [95% CI, 146.5-278.4] visits per 1000 patients).

Conclusions and Relevance This cohort study documented an excess health care burden of PCC in the 6 months after the acute stage of infection. As health care systems evolve during a highly dynamic and ongoing global pandemic, these data provide valuable evidence to inform long-term strategic resource allocation for patients previously infected with SARS-CoV-2.

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Article Information

Accepted for Publication: June 19, 2022.

Published: August 12, 2022. doi:10.1001/jamanetworkopen.2022.25657

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Tartof SY et al. JAMA Network Open.

Corresponding Author: Sara Y. Tartof, PhD, MPH, Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles, 2nd Floor, Pasadena, CA 91101 (sara.y.tartof@kp.org).

Author Contributions: Ms Liu and Dr Qian had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Tartof and Malden contributed equally.

Concept and design: Tartof, Malden, Sy, Weintraub, Qian.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tartof, Malden, Alpern, Weintraub.

Critical revision of the manuscript for important intellectual content: Malden, Liu, Sy, Lewin, Williams, Hambidge, Daley, Nelson, McClure, Zerbo, Henninger, Fuller, Weintraub, Saydah, Qian.

Statistical analysis: Tartof, Malden, Liu, Nelson, Weintraub, Qian.

Obtained funding: Tartof, Nelson.

Administrative, technical, or material support: Tartof, Malden, Sy, Lewin, Hambidge, Daley, McClure, Zerbo, Henninger, Weintraub, Saydah.

Supervision: Tartof, Malden, Weintraub.

Conflict of Interest Disclosures: Dr Tartof reported receiving grants from Pfizer and Genentech outside the submitted work. Dr Sy reported receiving grants from Moderna, GlaxoSmithKline, Dynavax Technologies, and Seqirus outside the submitted work. Dr Nelson reported receiving grants from Moderna, personal fees from Elsevier, Southern California Permanente Medical Group, and Heard Pilgrim Health Care outside the submitted work. Dr Fuller reported being an employee of Harvard Pilgrim Health Care Institute outside the submitted work. Dr Qian reported receiving grants from Moderna, GlaxoSmithKline, Dynavax Technologies, and Genentech outside the submitted work. No other disclosures were reported.

Funding/Support: This study was funded through the Vaccine Safety Datalink under contract No. 200-2012-53580 from the Centers for Disease Control and Prevention.

Role of the Funder/Sponsor: Although some authors are employed by the CDC, the CDC had no direct role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the CDC.

Additional Contributions: Cheryl Carlson, MPH, and Dawn Asamura, BA, provided project management support. Sungching Glenn, MS, provided programming consultation. Runxin Huang, MS, provided statistical support. Alfonso Hernandez, MBBCh; Jennifer Cope, MD; and Robert Bonacci MD, contributed subject matter expertise. They were not compensated outside of their usual salary.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.