Assessment of Post-COVID Symptoms Using the C19-YRS Tool in a Cohort of Patients from the First Pandemic Wave in Northwestern Spain

SAMPLE CHARACTERISTICS

Baseline patient characteristics of the 443 patients are summarized in Table 1. The mean age was 54 ± 16 years, 38.4% of patients were male, and 42.9% had some previous medical condition, the most frequent being hypertension (27.8% of patients). Eighty-seven patients (19.6%) needed hospitalization during the acute infection, and 10 (2.3%) needed admission to an ICU.

C19-YRS RESULTS: USE OF HEALTH RESOURCES AND WORK STATUS

Fifty-eight patients (13.1%) had consulted with their primary care provider after COVID-19, while 44 patients (9.9%) needed hospital care, either emergency room services or hospital admission, up to the moment of the interview. Hospital readmission was observed in 9.2% (8/87) of patients with an index hospitalization; of these, 5 cases were due to causes directly related to the infection.

Before COVID-19, 280 patients were actively employed (63.2%), 16 were unemployed (3.6%), and 5 (1.1%) were on a medical leave. From those employed before COVID-19, 10 (3.5%) patients lost their jobs, 4 of them directly due to the pandemic (1.4%). At the time of the survey 245 patients (55.3%) were actively employed, 29 (6.5%) were on a medical leave due to COVID-19 or its consequences, and 21 (4.7%) were unemployed. Thirty-four patients (7.7%) reported current difficulties in performing their usual duties at their jobs.

SYMPTOM ASSESSMENT

Results from the survey are shown in Table 2. Two hundred seventy-six (62.3%) patients complained of at least one symptom. The most affected domain was fatigue, reported in 165 (37.2%) versus 63 (14.2%) patients before COVID-19; new-onset fatigue was recorded in 102/380 patients (26.8%). The global fatigue score was significantly worse at the time of the interview (1.85 vs. 0.39, p < 0.001).

Breathlessness walking up a flight of stairs was also frequent with 148 patients (33.4%), reporting it at the time of the survey compared with 72 (16.3%) before the infection, with a new-onset ratio of 20.5% (76/371). A significant worsening in breathlessness while walking was observed (0.41 vs. 1.57; p < 0.001). Breathlessness at rest or while dressing was infrequent after the infection (3.4% and 5.6%, respectively), but scores were worse than before the disease (0.13 vs. 0.06, p = 0.003, and 0.25 vs. 0.09, p < 0.001, respectively).

Anxiety-related symptoms were also frequent: 131 (29.6%) patients reported anxiety at the time of the interview compared with 60 (13.5%) before COVID-19, with a new-onset ratio of 18.5% (71/383) and a significant increase of the anxiety score (1.52 vs. 0.44, p < 0.001). Pain and discomfort were reported by 111 (25.1%) patients compared with 36 (8.1%) before the infection, with a significant worsening of scores (1.07 vs. 0.22, p < 0.001).

Other severe less frequent symptoms were weight loss (15.1%), mobility impairment (21.9%), and posttraumatic stress-related symptoms (13.8% from which 59% were moderate or severe). Impairment of self-care ability (3.6%), swallowing (3.2%), and urinary incontinence (2.7%) were seldom reported, while no patients complained about fecal incontinence.

SUBGROUP ANALYSIS

The relationship between symptoms development and gender, age, presence of previous conditions, and hospitalization was investigated.

Female patients had significantly more pain of new onset (22.0% vs. 8.8%, p < 0.001), airway complaints (15.0% vs. 7.1%, p = 0.012), concentration (20.9% vs. 12.4%, p = 0.022), and short-term memory (25.3% vs. 15.9%, p = 0.020) impairment than males. Women also reported more fatigue than men (26.0% vs. 18.2%; p = 0.059), although the trend was not significant. Male patients presented a higher rate of swallowing difficulties (5.35 vs. 1.8%, p = 0.043). No differences were found in terms of health resource use or hospital readmission.

Patients younger than 65 years reported higher rates of pain and discomfort (20.1% vs. 8.3%, p = 0.003). Elderly patients presented more often weight loss (25.0% vs. 11.5%, p < 0.001), urinary incontinence (7.5% vs. 0.9%, p < 0.001), and short-term memory impairment (29.2% vs. 18.9%, p = 0.020) than their younger counterparts. Older patients also had a higher readmission rate (4.2% vs. 0.9%, p = 0.023) and a higher use of health resources (18.3% vs. 11.1%, p = 0.046).

Fatigue of new onset was rarer in patients with previous medical conditions (27.7% vs. 16.8%, p = 0.007), while they had a higher rate of weight loss (21.6% vs. 10.3%, p = 0.001), urinary incontinence (4.7% vs. 1.2%, p = 0.023), and unpleasant dreams (5.8% vs. 0.4%, p < 0.001) than previously healthy individuals. Comorbid patients had also a higher rate of hospital services consultation (14.7% vs. 6.3%, p = 0.003), primary care consultation (16.8% vs. 10.3%, p = 0.043), and readmission (3.7% vs. 0.4%, p = 0.010).

Finally, patients who had needed hospitalization reported higher rates of breathlessness at walking (28.7% vs. 14.3%, p = 0.001), weight loss (52.9% vs. 5.9%, p < 0.001), urinary incontinence (9.2% vs. 1.1%, p < 0.001), short-term memory impairment (37.9% vs. 17.7%, p < 0.001), and unpleasant dreams (6.9% vs. 1.7%, p = 0.007). This subgroup also needed more consultations with hospital services (28.7% vs. 5.3%, p < 0.001) and primary care (25.3% vs. 10.1%, p < 0.001) than patients with outpatient management.

Discussion

We present the results of the administration of the C19-YRS questionnaire to the survivors of the first pandemic wave. This telemedicine tool has been proven useful in the detection of emerging and worsening symptoms after the acute infection.⁸ In our study, two investigators with no previous training in the use of the questionnaire could reach >600 patients and record the answers of 443 in a relatively short time, spending an average of around 10 min per patient. Considering the high cumulated prevalence of SARS-CoV-2, this is an interesting characteristic for a long-COVID screening tool.

This can be particularly important given the high consumption of resources by COVID-19 patients. In our sample, 9.2% of patients who had been hospitalized needed readmission after the acute episode, in line with previous reports showing rates between 5%⁹ and 10%.¹⁰ The C19-YRS also revealed a sizeable use of outpatient services, which outlines the need for planned clinical pathways for these patients, which should stratify their condition and, if necessary, the severity of the problem.¹¹ Also, this tool allows for the profiling of the labor impact of the infection, revealing that 8.9% of workers were on a medical leave 10 months after the infection, and that 3.5% had lost their jobs. These results highlight the impact that the pandemic can have in the medium and long term beyond health and economic losses, specifically on the quality of life and mental health of patients.¹²

The most reported symptoms were fatigue and dyspnea, akin to what is described in other studies of virtual review of long-COVID symptoms^13,14 as well as in the present studies.⁶ The tool points also to some patient subgroups that might be more severely affected in the long term. Women had more impaired areas of symptoms than men, even when they had fewer pathologies and less request for hospital and ICU admission.

Previous studies have pointed to the female gender as a risk factor for greater involvement after acute SARS-CoV-2 infection,^13,15 as well as a worse health perception after any illness.^12,16 There are probably social and personal factors that contribute to this beyond biological differences, which should prompt a recalibration of our current approach to health-related quality of life in women. In addition, increasing age and previous medical conditions were linked to a higher use of health care resources; this has been reported in relation to COVID-19,¹⁷ but also before the pandemic.¹⁸

Overall, this study shows that C19-YRS, already endorsed by health authorities,¹ is a promising telemedicine tool that makes it possible to screen and assess large numbers of COVID-19 survivors for long-COVID symptoms, in a relatively fast, resource-sparing way. Although it has the usual pitfalls of a telephone questionnaire, namely, retrospective collection of data with inherent recall bias and difficulty of establishing causal relationships, it has already been validated.¹⁹ By using this tool on a considerable sample size with a high response rate, it allows for the detection and quantification of both health and occupational issues. Interestingly, results obtained using the C19-YRS are consistent with other studies reviewing postacute symptoms both remotely^13,14 and face-to-face.⁶ Once patients with problems have been identified, C19-YRS could be used as a tool to assess them during the follow-up.

Authors’ Contributions

B.A.G. and R.R.R. designed the study and screened the patients. A.P.L., A.R.Á., and Y.B.B. administered the survey and acquired the data. B.A.G. and Á.M.-L. performed the statistical analysis and conducted the plot elaboration. B.A.G. created the first draft of the article. E.R.L. and Maria J.G.P. participated in the data interpretation and edited the article. B.A.G. wrote the final draft of the article and implemented all the changes suggested by the coauthors. R.R.R. and J.C.S. reviewed and corrected the final article.

Ethical Commitment

This study was approved by the Santiago-Lugo Clinical Research Ethics Committee.

Data Availability

An anonymized copy of the data set used in this study can be obtained through the corresponding author.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.