Cost of Rehabilitation in Critically Ill COVID-19 Survivors

Dear Editor, The coronavirus disease 2019 (COVID-19) pandemic has resulted in over 79 million infected cases worldwide and more than a million deaths across 200 countries as of January 2021, imposing an immense logistical and economic burden on health-care systems. The medical cost incurred by the average critically ill COVID-19 survivor is anticipated to be substantial. Not unexpectedly, the cost of intensive care unit (ICU) stay is likely to amount to a significant portion of the total hospital expenditure. For a Singaporean citizen, the cost of stay per day in a local ICU is about S$980 (US$740.18) a day[1] (notwithstanding treatment, medical tests, consultation charges, etc.). The average stay of our cohort of COVID-19 survivors in the ICU was 19.7 days, indicating an average cost of S$19,306 (US$14581.57) for their total ICU stay. Added onto the cost will be the multitude of medical treatment and clinical tests performed. However, the cost burden of critical illness is not limited to ICU care. The impact of physical, cognitive, and emotional sequelae as a complication of COVID-19 critical illness extends beyond the patient's time in the ICU. We conducted a pilot study investigating the cost of rehabilitation in critically ill COVID-19 survivors to regain premorbid function in ambulation and activities of daily living (ADL). We retrospectively reviewed a series of 27 critically ill COVID-19 patients who required mechanical ventilation and were consecutively admitted to the ICU of the National Center for Infectious Diseases, Singapore, from January 1 to May 31, 2020. All critically ill patients who developed acute respiratory distress syndrome requiring mechanical ventilation with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection were included. Patients who were nonintubated and/or had died during ICU stay were excluded. All the patients were able to independently ambulate and perform ADL prior to contracting COVID-19. The patients were referred for physiotherapy, occupational therapy, and speech therapy sessions as clinically indicated, including during the ICU period in accordance with our hospital's clinical policy. They received inpatient rehabilitative therapy until they were medically fit for discharge. The study was approved by the ethics committee at our institution (NHG DSRB 2020/00639). The requirement for informed consent was waived by the hospital ethics commission. The total number of physiotherapy, occupational therapy, and speech therapy sessions was calculated during the whole hospitalization. Therapy cost was derived based on the cost per therapy session, i.e., S$89.88 (US$67.64) for each physiotherapy/occupational therapy session and S$69.55 (US$52.34) per speech therapy session. Each critically ill COVID-19 survivor underwent 17.3 physiotherapy, 6.11 occupational therapy, and 4.81 speech therapy sessions on average. The average cost of inpatient rehabilitative therapy was S$2438.63 (US$1835.25) per patient. Following inpatient rehabilitation, 85.2% (n = 23) achieved independence in ambulation, as well as their ADL on discharge from the hospital. A multivariate analysis of the data indicated that a longer duration of mechanical ventilation was associated with an increased need for therapy sessions (risk ratio 2.34, 95% confidence interval 0.868–3.82, P = 0.003) [Table 1]. The average duration of mechanical ventilation was 15 days for this cohort. Other risk factors such as age, disease severity, presence of comorbidities, and disease complications, were not significantly associated with the number of therapy sessions.Table 1: Risk factors for increased therapy sessionsDISCUSSION To our knowledge, this study represents the first description of the cost of rehabilitation among critically ill COVID-19 survivors. We found that a significant amount of rehabilitation was essential in optimizing the functional outcomes of critically ill COVID-19 survivors. Rehabilitation of ICU survivors is essential, particularly those with Post-Intensive Care Syndrome. This need is even more pertinent during the COVID-19 pandemic, given reports of long-term sequelae from severe COVID-19 pneumonia.[2] In line with the intensive care literature,[3] we found that patients with prolonged mechanical ventilation had higher burden of care, which presumably translated to an increased requirement for more therapy sessions as seen in our patient cohort. In our study, physiotherapy sessions account for the majority of the rehabilitative therapy required. We posit that this is due to the impoverished cardiorespiratory endurance and respiratory function brought upon by severe COVID-19 pneumonia and ICU-acquired weakness. Therefore, more such sessions were needed for strengthening and endurance training. Despite the need for rehabilitation, the cost of inpatient rehabilitative therapy is modest compared to the cost of ICU care. However, it is essential for the functional recovery of the COVID-19 ICU survivor. The success of rehabilitative therapy depends on not just the frequency of sessions, but also the early delivery of rehabilitation. Most of our patients had their first therapy session while in the ICU. This was continued when the patients were discharged from the ICU and into the general ward. Therapy intensity was adjusted according to each patient's prevailing medical condition and disease severity. A previous study revealed that most critically ill COVID-19 survivors had decreased quality of life and functional status at 6 months.[2] It is anticipated that most critically ill COVID-19 patients will require long-term follow-up and rehabilitation to restore mobility, independent living, and return to work. While our patients had achieved independence in mobility and self-care, outpatient follow-up therapy may be essential to ensure full integration into the community. More studies are required, as our findings were based on a single center with a small sample size. Other rehabilitation costs such as the personal protection equipment utilized, bed charges for inpatient rehabilitation, psychotherapy sessions, and physiatrist consultations were not studied. CONCLUSION Rehabilitation plays an important role in assisting COVID-19 afflicted individuals who are at risk of functional decline. This study provides an insight into the cost of delivery of rehabilitation for critically ill COVID-19 ICU survivors. As the number of COVID-19 cases continues to surge, it is crucial for policy planners to allocate adequate rehabilitative resources to safeguard the well-being of COVID-19 survivors. Further studies, evaluating the rehabilitative cost incurred by these patients in other contexts/settings, are necessary to better address such needs across the continuum of rehabilitative care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgment We thank all health-care staff who provided care for the patients at the National Centre for Infectious Diseases, Singapore.