| |

Received: 12 September 2020    Revised: 24 December 2020    Accepted: 18 February 2021

DOI: 10.1111/jocn.15733

ORIGINAL ARTICLE

Health-­related quality of life of COVID-­19 patients after

discharge: A multicenter follow-­up study

Guangbo Qu MD, Postgraduate Student1 | Qi Zhen PhD, Postgraduate Student2 |

Wenjun Wang PhD, Doctor2 | Song Fan PhD, Doctor3 | Qibing Wu PhD, Doctor4 |
Chengyuan Zhang MD, Doctor5 | Bao Li PhD, Unviersity Teacher6 | Gang Liu BS, Chief
Nurse7 | Yafen Yu PhD, Doctor2 | Yonghuai Li PhD, Doctor8 | Liang Yong PhD, Doctor2 |
Baojing Lu PhD, Doctor9 | Zhen Ding MD, Doctor10 | Huiyao Ge PhD, Doctor2 |
Yiwen Mao PhD, Doctor2 | Weiwei Chen MD, Doctor2 | Qiongqiong Xu MD, Doctor2 |
Ruixue Zhang MD, Doctor2 | Lu Cao MD, Doctor2 | Shirui Chen MD, Doctor2 | Haiwen Li
PhD, Doctor11 | Hui Zhang MD, Doctor2 | Xia Hu MD, Doctor2 | Jing Zhang PhD,
Doctor12 | Yonglian Wang MD, Doctor12 | Hong Zhang PhD, Doctor13 | Chaozhao Liang
PhD, Doctor3 | Liangdan Sun PhD, Doctor14 | Yehuan Sun PhD, University professor1

1
Department of Epidemiology and Health
Statistics, School of Public Health, Anhui Abstract
Medical University, Hefei, China
Aims and Objectives: To determine the health-­related quality of life (HRQoL) of
2
Department of Dermatology, The
First Affiliated Hospital of Anhui
COVID-­19 patients after discharge and its predicting factors.
Medical University, Key Laboratory of Background: COVID-­19 has caused a worldwide pandemic and led a huge impact on
Dermatology, Ministry of Education,
Inflammation and Immune Mediated
the health of human and daily life. It has been demonstrated that physical and psy-
Diseases Laboratory of Anhui Province, chological conditions of hospitalised COVID-­19 patients are impaired, but the studies
Anhui Medical University, Hefei, China
3
focus on physical and psychological conditions of COVID-­19 patients after discharge
Department of Urology, The First
Affiliated Hospital of Anhui Medical from hospital are rare.
University, Institute of Urology, Anhui Design: A multicentre follow-­up study.
Province Key Laboratory of Genitourinary
Diseases, Anhui Medical University, Hefei, Methods: This was a multicentre follow-­up study of COVID-­19 patients who had dis-
China charged from six designated hospitals. Physical symptoms and HRQoL were surveyed
4
Department of Radiation Oncology, The
at first follow-­up (the third month after discharge). The latest multiple laboratory find-
First Affiliated Hospital of Anhui Medical
University, Hefei, China ings were collected through medical examination records. This study was performed
5
Department of Respiratory and Critical and reported in accordance with STROBE checklist.
Care Medicine, East District of the First
Affiliated Hospital of Anhui Medical Results: Three hundred eleven patients (57.6%) were reported with one or more
University (Feidong People’s Hospital, physical symptoms. The scores of HRQoL of COVID-­19 patients at third month after
Feidong, China
6 discharge, except for the dimension of general health, were significantly lower than
The Comprehensive Lab, College of Basic,
Anhui Medical University, Hefei, China Chinese population norm (p < .001). Results of logistic regression showed that female
7
Department of Critical Care Medicine, (odds ratio (OR): 1.79, 95% confidence interval (CI): 1.04–­3.06), older age (≥60 years)
The First Affiliated Hospital of Anhui
Medical University, Hefei, China
(OR: 2.44, 95% CI: 1.33–­4.47) and the physical symptom after discharge (OR: 40.15,

Qu, Zhen, Wang, Fan, Wu and Zhang contributed equally to this manuscript.

J Clin Nurs. 2021;00:1–9. wileyonlinelibrary.com/journal/jocn© 2021 John Wiley & Sons Ltd     1 |
 |
2      QU et al.

8
Department of Respiratory and Critical
Care Medicine, The First Affiliated 95% CI: 9.68–­166.49) were risk factors for poor physical component summary; the
Hospital of Anhui Medical University,
physical symptom after discharge (OR: 6.68, 95% CI: 4.21–­10.59) was a risk factor for
Hefei, China
9
Department of Microbiology, School of
poor mental component summary.
Basic Medical Science, Anhui Medical Conclusions: Health-­related quality of life of discharged COVID-­19 patients did not
University, Hefei, China
10
come back to normal at third month after discharge and affected by age, sex and the
Department of Respiratory Medicine,
Binhu Hospital of Hefei, Hefei, China physical symptom after discharge.
11
The Third Affiliated Hospital of Anhui Relevance to clinical practice: Healthcare workers should pay more attention to the
Medical University, The First Affiliated
physical and psychological rehabilitation of discharged COVID-­19 patients. Long-­term
Hospital of Zhengzhou University,
Zhengzhou, China follow-­up on COVID-­19 patients after discharge is needed to determine the long-­term
12
The Second People's Hospital of Hefei, impact of COVID-­19.
Hefei, China
13
Emergency Department, First Affiliated KEYWORDS
Hospital of Anhui Medical University,
clinical, COVID-­19, discharge, health-­related quality of life, SARS-­CoV-­2
Hefei, China
14
Department of Dermatology, The
First Affiliated Hospital of Anhui What does this paper contribute to the wider global clinical community?
Medical University, Key Laboratory of • This paper reveals the situation of health-­related quality of life of COVID-­19 patients at the
Dermatology, Ministry of Education,
third month after discharge from hospital.
Inflammation and Immune Mediated
Diseases Laboratory of Anhui Province, • This paper has determined several factors that predict poor health-­related quality of life for
Anhui Provincial Institute of Translational COVID-­19 patients after discharge.
Medicine, Anhui Medical University,
Hefei, China

Correspondence
Liangdan Sun, Department of
Dermatology, The First Affiliated
Hospital of Anhui Medical University,
Key Laboratory of Dermatology, Ministry
of Education, Inflammation and Immune
Mediated Diseases Laboratory of Anhui
Province Anhui Medical University, Hefei,
China.
Yehuan Sun, Department of Epidemiology
and Health Statistics, School of Public
Health, Anhui Medical University, Hefei,
China.
Email: (LS); yhsun_ahmu_edu@yeah.net
(YS)

Funding information
This study was supported by the National
Ten Thousand-­Person Program for
Leading Talents in Science and Technology
Innovation and the Research Fund of
Anhui Institute of Translational Medicine
(ZHYX2020A005).

1  |  I NTRO D U C TI O N caused a worldwide pandemic and led a huge impact on the health
of human and daily life. To date, there are more than twenty mil-
Coronavirus disease 2019 (COVID-­19) is a novel pneumonia in- lion confirmed cases and seven hundred thousand cases died with
fection with severe acute respiratory syndrome coronavirus 2 COVID-­19 infection worldwide according to the reports of World
(SARS-­CoV-­2), a member of the betacoronavirus genus. The main Health Organization (WHO) (World Health Organization, 2020).
clinical characteristics of COVID-­19 are fever, cough and shortness Previous studies have revealed some positive laboratory findings
of breath (Chen, Zhou, et al., 2020), and a proportion of patients may and reactivated clinical features of discharged COVID-­19 patients
accompany with new loss of taste or smell (Dawson et al., 2020), (Zheng et al., 2020). As reviewed by Zheng and colleagues (Zheng
diarrhoea, nausea, vomiting and other symptoms (Chen, Zhou, et al., et al., 2020), approximately 3.2% to 9.1% of discharged patients may
2020; Kim et al., 2020; Tian et al., 2020). Currently, COVID-­19 has experience SARS-­COV-­2 reactivation but without specific clinical
QU et al. |
      3

features to distinguish them. Some clinical symptoms including fever, definitely diagnosed with SARS-­CoV-­2 infection on hospital admis-
cough, sore throat and fatigue were also observed among discharged sion (the diagnosis of SARS-­CoV-­2 infection was based on guideline
patients with SARS-­COV-­2 reactivation (Ye et al., 2020; Zheng et al., for the diagnosis and treatment of 2019 novel coronavirus (2019-­
2020). In addition, due to incomplete recovery of pulmonary injury, nCoV) infected pneumonia of Chinese: positive for the 2019-­nCoV
present palpitation, shortness of breath or dyspnoea may still occur by the real-­time PCR test for nucleic acid in respiratory or blood
after physical activity for discharged patients (Zheng et al., 2020). samples); (2) hospitalisation for the following reasons: fever (axillary
Another concern is that considering the impact of coronavirus infec- temperature was 36.7°C and above, or oral temperature was 38.0°C
tion on the daily life and work, a considerable number of COVID-­19 and above, or anal temperature or ear temperature was 38.6°C and
patients may still have psychological problems after discharge from above) and respiratory rate was more than 24 times/min or cough
hospital (Yuan et al., 2020). Therefore, all mentioned above suggests (at least one of shortness of breath and cough); (3) the clinical type
that the physical and mental functions of some discharged patients of COVID-­19 at hospital admission was mild to severe according to
do not come back to normal and at the risk of deterioration. the Chinese management guideline for COVID-­19 (Sixth edition);
and (4) participants were required to meet the standard hospital dis-
charge criteria (no fever for at least 3 days; substantial resolution of
2  |   BAC KG RO U N D pneumonia with a CT scan, two negative SARS-­CoV-­2 RT-­qPCR tests
done at least 1  day apart on nasopharyngeal and oropharyngeal
Health-­related quality of life (HRQoL) has aroused much interest in swabs, and no concurrent acute medical issues requiring transfer to
the social progress and the transformation of medical care and ser- another medical facility). The exclusion criteria of participants were
vice systems, which refers to the impact of disease and treatment as follows: (1) confirmed hepatitis B, C, AIDS and other viral infec-
on patients' function and overall life satisfaction (Gill & Feinstein, tions; (2) women who were in pregnancy (positive pregnancy test for
1994; Schipper et al., 1996). Similar to other diseases, it has been women of childbearing age); (3) subjects with other unsuitable fac-
demonstrated in several studies that COVID-­19 can affect HRQoL tors considered by the researchers; and (4) discharged patients were
of patients and general populations (Nguyen et al., 2020; Zhang & unwilling to participate in this study.
Ma, 2020). Physical symptoms are still observed among COVID-­19 Five hundred eighty one discharged patients (including 511 mild
patients after discharged from hospital (Carfì et al., 2020), which or moderate COVID-­19 patients and 70 severe COVID-­19 patients)
may also affect their normal life and lead to poor HRQoL. However, were invited to participate in this study and would be first informed
only few studies have reported HRQoL of patients after discharge. of the purpose and benefits of this study through telephone, and
One previous cross-­sectional study has revealed that HRQoL was after obtaining the patients' verbal consent, an electronic survey
poor among COVID-­19 patients at the first-­month follow-­up and form would be given to patients to collect interest data. For younger
several risk factors are determined (Chen et al., 2020). Garrigues participants (aged less than 18), the survey was conducted in the
et al., (2020) have found that there are few differences for HRQoL company of parents and with the consent of parents and children.
between ward and ICU COVID-­19 patients after discharge. Finally, a total of 540 discharged patients were included in our
Considering studies reporting physical and psychological condi- study (Figure 1). All included patients had been discharged be-
tions of COVID-­19 patients after discharge from hospital are rare, tween 1 February 2020–­8 March 2020 (the latest patient was dis-
this multicentre study was performed to investigate the physi- charged from hospitals). The study was started on 5 May 2020 and
cal condition and HRQoL of COVID-­19 patients after discharge. ended on 8 June 2020. This study was approved by the Research
Meanwhile, factors associated with poor health-­related quality of Ethics Commission of the First Affiliated Hospital of Anhui Medical
life were also explored. University (PJ-­2020–­03–­19). Written informed consent was waived
by the Ethics Commission for emerging infectious diseases.

3  |   M E TH O D S
3.2  |  Data collection
3.1  |  Study design and participants
Data were collected at the first follow-­up hospital appointment fol-
This study was performed and reported in accordance with lowing discharge which is routinely offered to patients at 3 months.
Strengthening the Reporting of Observational Studies in An electronic survey form was administered to discharged COVID-­19
Epidemiology guideline for cohort studies (Supplementary File 1). patients to collect the information of physical symptoms and HRQoL.
This was a multicentre follow-­up study of COVID-­19 patients who Physical symptoms were self-­reported by patients. According to the
had been discharged from designated hospitals in Anhui Province discharge regulations of COVID-­19, patients should undergo routine
and Hubei Province. Six designated hospitals in Anhui Province examination after discharge in community hospitals or grade A hos-
and Hubei Province for the treatment of COVID-­19 were selected pitals with inspection qualifications. Results of multiple laboratory
to recruit discharged patients with COVID-­19 infection. The inclu- examination were collected through medical examination records.
sion criteria of participants were as follows: (1) the patients were Times from hospital discharge to laboratory examination were
 |
4      QU et al.

TA B L E 1  Characteristics of discharged COVID-­19 patients and

the Chinese general population

Percentage Chinese general

Variables Number (%) population (%)a 

Sex
Male 270 50.0 51.1
Female 270 50.0 48.9
Age (years)
10–­19 8 1.5 11.9
20–­39 166 30.7 33.1
40–­59 257 47.6 34.8
60–­79 105 19.4 17.8
80–­99 4 0.7 2.4
Severity of COVID−19
Mild or 489 90.6 NA
moderate

F I G U R E 1  Flow chart of this study Severe 51 9.4 NA

Physical symptoms
Fatigue 159 29.4 NA
recorded. In our study, the collected medical laboratory examination
results include SARS-­CoV-­2 RNA detection (positive or negative), Cough 63 11.7 NA

blood routine examination (white blood cell count, haemoglobin, Sputum 54 10.0 NA

platelet, C-­reactive protein, neutrophil-­to-­lymphocyte ratio), and Dyspnoea 38 7.0 NA

renal and liver function (aspartate aminotransferase, alanine ami- Diarrhoea 36 6.7 NA
notransferase, total bilirubin, blood urea nitrogen, serum creatinine). Shortness of 141 26.1 NA
All data were collected by the physicians who managed and took the breath
most care of COVID-­19 patients and checked by the third research- Joint pain 131 26.3 NA
ers. There were no missing data collected in our study. Dysbasia 22 4.1 NA
Palpitations 110 20.4 NA
Other 120 22.2 NA
3.3  |  Health-­related quality of life symptoms
Number of physical symptoms
Health-­related quality of life was assessed using the scale of MOS 0 229 42.4 NA
36-­item Short-­Form Health Survey (SF-­36). SF-­36 is a generic widely 1 93 17.2 NA
validated scale to measure HRQoL of inpatient or discharged patients
2 72 13.3 NA
which include eight health concepts (Brazier et al., 1992): physical func-
3 48 8.9 NA
tion (PF), role physical (RP), bodily pain (BP), general health (GH), vitality
4 49 9.1 NA
(VT), social function (SF), role emotion (RE) and mental health (MH). The
≥5 49 9.1 NA
assessed scores of each concept were ranged from 0–­100, and higher
scores represent better quality. In addition, eight health concepts of SF-­ Abbreviation: NA, not applicable.
a
36 can be classified into two categories: physical component summary Data were reported from Chinese National Bureau of Statistics (2019)
(http://www.stats.gov.cn/tjsj/ndsj/).
(PCS) and mental component summary (MCS), and the poor HRQoL
was defined as scores of PCS or MCS less than 50 (Chen, Li, et al., 2020).
In our study, the overall Cronbach's alpha of this scale was 0.547. The were presented as number and percentage. The HRQoL scores
Chinese population norm (Rui et al., 2011) was used as the comparison were compared between two groups using t tests, and Cohen's d
to determine whether the HRQoL of COVID-­19 patients after discharge effect size was calculated. The magnitudes of absolute Cohen's d
was poorer than general population. effect size was classified into four categories: negligible (<0.2), small
(0.2–­0.49), moderate (0.5–­0.79) and large (>0.79) (Cohen, 1988).
The chi-­squared tests or Fisher's exact tests were used to compare
3.4  |  Statistical analyses the difference in categorical variables. Furthermore, univariate and
multivariate logistic regressions were conducted to explore the fac-
Continuous variables were described as median and interquartile tors associated with poor HRQoL. All variables that were significant
range (IQR) or mean and standard deviation (SD). Count variables (p < .05) in univariate logistic regression models would be included in
TA B L E 2  Comparison of HRQoL scores among discharged COVID-­19 patients with different characteristics and Chinese population norm

PF RP BP GH VT SF RE MH PCS MCS
QU et al.

Participants
Patients in this 87.17 ± 14.57 66.30 ± 41.04 79.48 ± 20.73 68.90 ± 22.16 55.35 ± 14.58 66.41 ± 24.51 71.30 ± 38.70 22.86 ± 14.00 75.46 ± 20.45 53.98 ± 13.87
study
Chinese norm 94.02 ± 12.44 88.79 ± 28.49 88.18 ± 19.02 69.74 ± 20.95 68.92 ± 18.78 88.03 ± 16.00 89.57 ± 27.95 77.61 ± 15.85 NA NA
p value* <.001 <.001 <.001 .393 <.001 <.001 <.001 <.001 NA NA
Cohen's d −0.51 −0.64 −0.44 −0.04 −0.81 −1.04 −0.54 −3.66 NA NA
Severity of COVID−19
Mild or 87.90 ± 12.89 66.31 ± 40.76 79.78 ± 20.32 69.03 ± 21.96 55.48 ± 14.26 66.36 ± 24.27 71.30 ± 39.49 22.87 ± 13.87 75.75 ± 19.86 54.00 ± 13.70
moderate
Severe 80.10 ± 24.69 66.18 ± 44.11 76.63 ± 24.34 67.71 ± 24.16 54.12 ± 17.46 66.91 ± 26.90 71.24 ± 41.11 22.74 ± 15.38 72.65 ± 25.52 53.75 ± 15.56
*
p value .03 .983 .376 .685 .526 .879 .992 .951 .403 .913
Cohen's d 0.40 0.003 0.14 0.06 0.09 −0.02 0.001 0.01 0.14 0.02
Sex of patients
Male 89.24 ± 13.85 72.59 ± 38.73 82.99 ± 20.03 72.67 ± 21.09 56.85 ± 14.35 68.06 ± 23.72 76.05 ± 36.73 21.39 ± 13.30 79.37 ± 19.19 55.59 ± 13.33
Female 85.09 ± 14.99 60.00 ± 42.37 75.97 ± 20.85 65.13 ± 22.59 53.85 ± 14.67 64.77 ± 25.21 66.54 ± 40.08 24.33 ± 14.55 71.55 ± 20.96 52.37 ± 14.23
p value* .001 <.001 <.001 <.001 .017 .119 .004 .015 <.001 .007
Cohen's d 0.29 0.31 0.34 0.35 0.21 0.13 0.25 −0.21 0.39 0.23
Age of patients
<60 years 88.58 ± 13.35 67.40 ± 40.55 80.23 ± 20.67 69.97 ± 22.73 55.29 ± 14.73 65.66 ± 24.02 71.23 ± 39.08 22.86 ± 14.16 76.55 ± 20.31 53.76 ± 13.90
≥60 years 81.56 ± 17.61 61.93 ± 42.84 76.50 ± 20.77 64.70 ± 19.24 55.60 ± 14.04 69.38 ± 26.27 71.56 ± 37.36 22.86 ± 13.42 71.17 ± 20.55 54.85 ± 13.76
*
p value <.001 .214 .093 .015 .845 .157 .937 .998 .014 .464
Cohen's d 0.45 0.13 0.18 0.25 −0.02 −0.15 −0.01 0 0.26 −0.08
Physical symptoms
No 94.17 ± 9.43 88.21 ± 26.34 91.76 ± 14.22 82.37 ± 16.03 63.14 ± 11.45 75.66 ± 22.93 90.54 ± 23.42 16.94 ± 11.59 89.13 ± 11.56 61.57 ± 9.28
Yes 82.01 ± 15.51 50.16 ± 42.45 70.44 ± 20.12 58.99 ± 20.79 49.61 ± 13.97 59.61 ± 23.41 57.13 ± 41.54 27.22 ± 14.04 65.40 ± 19.74 48.39 ± 14.04
p value* <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001
Cohen's d 0.95 1.08 1.22 1.26 1.06 0.69 0.99 −0.80 1.47 1.11
SARS-­COV−2 reactivation
No 87.02 ± 14.66 65.99 ± 41.20 79.30 ± 20.71 68.88 ± 22.23 55.35 ± 14.74 66.19 ± 24.76 71.00 ± 38.70 22.99 ± 14.08 75.30 ± 20.55 53.88 ± 14.00
Yes 89.53 ± 12.97 71.09 ± 38.68 82.34 ± 21.03 69.22 ± 21.32 55.31 ± 11.77 69.92 ± 20.04 76.04 ± 39.02 20.75 ± 12.71 78.05 ± 19.06 55.51 ± 11.67
*
p value .344 .496 .421 .934 .987 .404 .475 .380 .462 .521
Cohen's d −0.18 −0.13 −0.15 −0.02 0.003 −0.17 −0.13 0.17 −0.14 −0.13

Abbreviations: BP, bodily pain; GH, general health; HRQoL, health-­related quality of life; MCS, mental component summary; MH, mental health; NA, not available; PCS, physical component summary; PF,
|

physical function; RE, role emotion; RP, role physical; SF, social function; VT, vitality.
      5

*p value was determined by independent t test.

Bold values indicate that the comparison between groups is statistically significant.
 |
6      QU et al.

multivariate logistic regression models. All statistical analyses were those with physical symptoms (p < .001), and all discrepancies were
performed using SPSS software, version 23.0, and significance was moderate or large (absolute Cohen's d: 0.69 to 1.26).
set at p < .05 (two-­sided).

4.3  |  Variables associated with HRQoL

4  |  R E S U LT S
In our study, 83 patients had poor PCS (15.4%) and 176 patients had
4.1  |  Characteristics of patients poor MCS (32.6%). The comparison of laboratory findings among pa-
tients with different classification of HRQoL is shown in Table 3. We
Demographic characteristics of patients and physical symptoms are found that patients with poor PCS only had poor haemoglobin and
presented in Table 1. Of the 540 discharged COVID-­19 patients who albumin. Several factors associated with poor PCS and MCS were
had participated in this study, 489 patients were diagnosed with identified in univariate logistic regression models (Table S1). Results
mild or moderate COVID-­19, and 51 patients were diagnosed se- of multivariate logistic regression indicated that female (odds ratio
vere COVID-­19 patients. The median age of all discharged patients (OR): 1.79, 95% CI: 1.04–­3.06, p = .035), older age (≥ 60 years) (OR:
was 47.50  years (IQR: 37.00–­57.00), and male patients accounted 2.44, 95% CI: 1.33–­4.47, p = .004) and physical symptoms (OR: OR:
for 50.0%, and the sex ratio of our study samples was similar to 40.15, 95% CI: 9.68–­166.49, p < .001) were risk factors for poor PCS;
Chinese general population, but the proportion of patients for the the physical symptom after discharge (OR: 6.68, 95% CI: 4.21–­10.59,
age group 40–­99 years was higher than the general Chinese popula- p < .001) was a risk factor for poor MCS (Table 4).
tion (Table 1). In total, 311 patients (57.6%) were reported with one
or more uncomfortable physical symptoms. Fatigue (29.4%) was the
most common symptom reported by discharged COVID-­19 patients, 5  |  D I S C U S S I O N
followed by shortness of breath after light physical activity (26.1%)
and joint pain (24.3%). In addition, 32 patients (5.9%) presented with Most of the researches have focused on the HRQoL of hospitalised
SARS-­COV-­2 reactivation, mainly within 1–­2 weeks after discharge COVID-­19 patients, but few have revealed HRQoL in post-­discharge
from the hospital (timeline of 32 patients with SARS-­COV-­2 reacti- COVID-­19 patients. Our study comprehensively investigated the
vation is presented in Figure S1). HRQoL of COVID-­19 patients after discharge from hospital and also
explored its risk factors. For the HRQoL of discharged COVID-­19
patients, we found that except for GH dimension, scores of all other
4.2  |  HRQoL of COVID-­19 patients after discharge dimensions of SF-­36 were significantly lower than Chinese norm,
which indicated that the HRQoL of COVID-­19 patients was impaired
The comparison of scores HRQoL scores among different groups is and did not come back to normal even at three months after dis-
presented in Table 2. Compared with Chinese population norm, ex- charge. These findings were consistent with previous studies (Santus
cept for GH dimension, all scores of other dimensions of SF-­36 in et al., 2020; van der Sar-­van der Brugge et al., 2020). Healthcare
COVID-­19 patients were significantly lower (p < .001) and the values workers need to pay attention to physical and psychological condi-
of effect size showed that the discrepancy was small for BP (absolute tions at long-­term recovery of COVID-­19 patients. Nevertheless, the
Cohen's d: 044.), moderate for PF, RP and RE (absolute Cohen's d: finding of our study was partly different with a follow-­up study con-
0.51 to 0.64), and large for VT (absolute Cohen's d: 0.81) and MH ducted by Chen, Li, et al., (2020) who found that at one month after
(absolute Cohen's d: 3.66). Severe COVID-­19 patients had lower discharge, there was no difference in PF score between COVID-­19
scores of PF than mild or moderate COVID-­19 patients after dis- patients and Chinese population norm, but the scores of BP, GH, VT
charge (p = .030), and the discrepancy was small (absolute Cohen's d: and MH were significantly higher and scores of RP, SF and RE were
0.40). For different sex of patients, significant difference in physical significantly lower in COVID-­19 patients than the Chinese popula-
and mental health status found that except for SF, male patients had tion norm. Possible causes for these differences can be explained by
higher scores of PF, RP, GH and VT and lower scores of MH than the differences in population characteristics that our study included
female, and the discrepancy was small (absolute Cohen's d: 0.21 to more older COVID-­19 patients and HRQoL of COVID-­19 patients
0.39), which meant that male had better quality of physical and men- was investigated at three months after discharge.
tal health after discharge. We also found that patients younger than Results of multivariate logistical regression indicated that HRQoL
60 years had significant higher scores of PF and GH, than those older of discharged COVID-­19 patients was affected by some factors, that
than 60 years, and the discrepancy was small (absolute Cohen's d: is, female, older age (≥60  years) and physical symptoms after dis-
0.45 and 0.25, respectively), which indicated that older patients may charge were risk factors for poor PCS, and the physical symptom
have poor physical and mental health recovery status than younger after discharge was a risk factor for poor MCS. These findings were
patients. In addition, COVID-­19 patients without physical symptoms in line with a previous follow-­up study that older age and female
after discharge showed significantly higher HRQoL scores than were risk factors for poor HRQoL (Chen, Li, et al., 2020). As we all
QU et al.       7|
TA B L E 3  Comparison of laboratory findings among different classification of HRQoL

Poor PCS Poor MCS

p
Laboratory findings Yes No p value Yes No value

White blood cell count (109/L) 5.81 ± 1.25 6.13 ± 1.42 .055 5.94 ± 1.34 6.16 ± 1.43 .091
<4 7 (8.4%) 19 (4.2%) .128 12 (6.8%) 14 (3.9%) .183
4–­10 76 (91.6%) 428 (94.1%) 163 (92.6%) 341 (94.2%)
>10 0 (0.0%) 8 (1.8%) 1 (0.6%) 7 (1.9%)
Haemoglobin (g/L) 134.63 ± 24.39 140.05 ± 21.30 .038 137.71 ± 20.89 139.91 ± 22.32 .268
<113 9 (10.8) 27 (5.9) .165 14 (8.0%) 22 (6.1%) .728
113–­172 72 (86.7) 423 (93.0) 160 (90.9%) 335 (92.5%)
>172 2 (2.4) 5 (1.1) 2 (1.1%) 5 (1.4%)
Platelet (109/L) 217.95 ± 54.59 221.84 ± 54.68 .551 217.67 ± 53.61 222.98 ± 55.11 .291
≥100 82 (98.8%) 452 (99.3%) .489 175 (99.4%) 359 (99.2%) 1.000
<100 1 (1.2%) 3 (0.7%) 1 (0.6%) 3 (0.8%)
C-­reactive protein (mg/L) 6.84 ± 8.87 5.44 ± 12.01 .320 5.97 ± 9.84 5.50 ± 12.38 .663
≤5 51 (63.0%) 316 (72.6%) .078 115 (65.7%) 252 (73.9%) .052
>5 30 (37.0%) 119 (27.4) 60 (34.3%) 89 (26.1%)
Aspartate aminotransferase 24.17 ± 9.86 26.97 ± 16.00 .125 26.18 ± 14.50 26.71 ± 15.60 .707
(U/L)
≤40 78 (95.1%) 412 (92.2) .347 162 (94.2%) 328 (91.9%) .341
>40 4 (4.9%) 35 (7.8%) 10 (5.8%) 29 (8.1%)
Alanine aminotransferase 30.93 ± 20.18 33.24 ± 22.58 .387 32.88 ± 22.69 32.88 ± 22.03 .998
(U/L)
≤40 58 (70.7%) 325 (72.2%) .782 119 (68.8%) 264 (73.5%) .253
>40 24 (29.3%) 125 (27.8%) 54 (31.2%) 95 (26.5%)
Total bilirubin (µmol/L) 12.86 ± 4.76 12.87 ± 4.74 .990 12.92 ± 4.47 12.84 ± 4.87 .858
≤21 78 (95.1%) 416 (93.5%) .574 163 (94.2%) 331 (93.5%) .750
>21 4 (4.9%) 29 (6.5%) 10 (5.8%) 23 (6.5%)
Albumin (g/L) 46.14 ± 9.37 46.48 ± 6.01 .676 46.21 ± 7.78 46.53 ± 6.01 .605
<40 6 (7.3%) 22 (4.9%) .047 10 (5.8%) 18 (5.1%) .414
40–­55 70 (85.4%) 412 (92.6%) 155 (89.6%) 327 (92.4%)
>55 6 (7.3%) 11 (2.5%) 8 (4.6%) 9 (2.5%)
Blood urea nitrogen (mmol/L) 4.62 ± 1.43 4.49 ± 1.37 .438 4.45 ± 1.38 4.54 ± 1.38 .504
≤7.5 80 (97.6%) 432 (99.5%) .121 171 (98.3%) 341 (99.7%) .114
>7.5 2 (2.4%) 2 (0.5%) 3 (1.7%) 1 (0.3%)
Serum creatinine (mmol/L) 59.98 ± 11.80 60.73 ± 10.16 .559 60.35 ± 12.02 60.75 ± 9.51 .684
≤133 77 (100.0%) 406 (100.0%) NA 166 (100.0%) 317 (100.0%) NA
>133 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

Abbreviations: HRQoL, health-­related quality of life; MCS, mental component summary; PCS, physical component summary.

know, physical symptoms are closely related to poor physical func- previous study has demonstrated that women had a worse PCS recov-
tion and great psychological burden (Nunes et al., 2017; Speed et al., ery than men because women perceived greater psychological stress
2017; Storm Van’s Gravesande et al., 2019); therefore, it is not sur- (Xu et al., 2015). Therefore, this may be why poorer PCS in women
prising that our study found the physical symptom to be a risk factor was observed in our study. However, with the outbreak of COVID-­19,
for poor HRQoL. In our study, compared with male patients, female women have perceived a significant higher level of post-­traumatic
patients presented with significant lower scores of all dimensions of stress than men (Liu et al., 2020). It has been demonstrated that in
SF-­36, which indicated that HRQoL of female was much poorer than general population, women are more susceptible to a series of psy-
male. However, results of multivariate logistical regression indicated chological problems (such as anxiety and depression) than men during
that female was a risk factor for poor PCS but not for poor MCS. A the outbreak of COVID-­19 (Wang et al., 2020; Zhou et al., 2020). In
 |
8      QU et al.

TA B L E 4  Results of multivariate logistic regression for HRQoL of

discharged COVID-­19 patients.
6  |  CO N C LU S I O N

p In conclusion, physical symptoms were common among COVID-­19

Outcomes Variables OR (95% CI) value
patients after discharge, which needs much attention. HRQoL of
Poor PCS Sex (female vs. 1.79 (1.04–­3.06) .035 COVID-­19 patients was impaired and did not come back to normal
male)
at third month after discharge. HRQoL was significantly associated
Age (≥60 years 2.44 (1.33–­4.47) .004
with age, sex and physical symptoms after discharge.
vs. <60 years)
Physical 40.15 (9.68–­166.49) <.001
symptoms
(yes vs. no) 7  |  R E LE VA N C E TO C LI N I C A L PR AC TI C E
Albumin (g/L) 1.78 (0.80–­3.98) .158
(<40 or >55 Healthcare workers should pay more attention to the physical and
vs. 40–­50) psychological rehabilitation of discharged COVID-­19 patients, es-
Poor MCS Sex (female vs. 1.27 (0.86–­1.88) .233 pecially for female and older patients. Long-­term follow-­up on
male) COVID-­19 patients is needed to determine the dynamic recovery of
Physical 6.68 (4.21–­10.59) <.001 HRQoL.
symptoms
(yes vs. no)
C O N FL I C T O F I N T E R E S T S
Abbreviations: CI, confidence interval; COVID-­19, coronavirus disease All authors disclosed no conflict of interest.
2019; HRQoL, health-­related quality of life; MCS, mental component
summary; OR, odds ratio; PCS, physical component summary.
ORCID
Yehuan Sun  https://orcid.org/0000-0002-8651-8059
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