The health-related quality of life in patients with post-COVID-19 after hospitalization: a systematic review

Figueiredo, Eduardo Augusto Barbosa; Silva, Whesley Tanor; Tsopanoglou, Sabrina Pinheiro; Vitorino, Débora Fernandes de Melo; Oliveira, Luciano Fonseca Lemos de; Silva, Keity Lamary Souza; Luz, Hiago Daniel Herédia; Ávila, Matheus Ribeiro; Oliveira, Lucas Fróis Fernandes de; Lacerda, Ana Cristina Rodrigues; Mendonça, Vanessa Amaral; Lima, Vanessa Pereira; Mediano, Mauro Felippe Felix; Figueiredo, Pedro Henrique Scheidt; Rocha, Manoel Otávio Costa; Costa, Henrique Silveira

doi:10.1590/0037-8682-0741-2021

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Review Article • Rev. Soc. Bras. Med. Trop. 55 • 2022 • https://doi.org/10.1590/0037-8682-0741-2021 copy

The health-related quality of life in patients with post-COVID-19 after hospitalization: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Symptoms in post-COVID-19 patients who require hospitalization can persist for months, significantly affecting their health-related quality of life (HRQoL). Thus, the present study aimed to discuss the main findings regarding HRQoL in post-COVID-19 patients who required hospitalization. An electronic search was performed in the MEDLINE, EMBASE, CINAHL, Web of Science, LILACS, and Scopus databases, without date and language restrictions, until July 2021. Twenty-four articles were included in the analysis. It seems that HRQoL partially improved soon after hospital discharge, although the negative impact on HRQoL may persist for months. The physical and mental aspects are affected because patients report pain, discomfort, anxiety, and depression. The HRQoL of COVID-19 infected patients was worse than that of uninfected patients. Additionally, HRQoL seemed worse in patients admitted to the intensive care unit than in those who remained in the ward. Improvements in HRQoL after hospital discharge are independent of imaging improvement, and there seems to be no association between HRQoL after hospital discharge and disease severity on hospital admission. Many factors have been identified as determinants of HRQoL, with women and advanced age being the most related to worse HRQOL, followed by the duration of invasive mechanical ventilation and the need for intensive care. Other factors included the presence and number of comorbidities, lower forced vital capacity, high body mass index, smoking history, undergraduate education, and unemployment. In conclusion, these findings may aid in clinical management and should be considered in the aftercare of patients.

Keywords:
COVID-19; SARS-CoV-2; Hospitalization; Quality of life

Study	Sample characteristics	Objective related to HRQoL	Instrument	Follow-up	Outcomes	Methodological quality	Overall quality
Daher et al., 2020	n=33 patients after severe COVID-19 (mean 64.0 years, SD 3.0, 67% males; mean length of stay 15 days, SD 1.8)	To verify the HRQoL of patients after severe COVID-19 infection and to compare it with the HRQoL at the time of hospital admission.	EQ-5D-5L and SGRQ	6 weeks after hospital discharge	At the end of follow-up period, patients reported slight to moderate abnormalities in mobility, self-care, usual activities, pain/discomfort and anxiety/depression by EQ-5D-5L.	Selection (★★) Comparability (-) Exposure (★★★) Total score: 5/9	Low quality
Maheshwari et al., 2021	n=51 convalescent plasma donors who recovered from COVID-19 and were symptom free and negative (mean 34.37 years, SD 9.08, 90.2% males).	To analyze the psychological impact of COVID-19 among convalescent recovered plasma donors.	WHOQOL-Bref	Not reported	The worst affected WHOQOL-Bref domain was the physical, followed by environmental, psychological, and social relationships.	Selection (★★) Comparability (-) Exposure (★★★) Total score: 5/9	Low quality
Méndez et al., 2021	n=179 patients who were hospitalized with COVID-19 (ages ranging from 22 to 81 years, 41.3% females)	To assess the HRQoL and psychiatric symptoms in post-COVID-19 survivors after hospital discharge.	SF-12	2 months after hospital discharge	Low HRQoL for physical and mental components was detected in 44.1% and 39.1% of patients, respectively.	Selection (★★★★) Comparability (-) Exposure (★★) Total score: 6/9	Low quality
Monti et al., 2021	n=39 patients after intensive care unit discharge [mean 56 years, SD 10.5, 10.0% females, after mechanical ventilation for a median of 9 (6-14) days].	To assess the HRQoL of survivors of Severe Acute Respiratory Syndrome by COVID-19 ventilated invasively.	EQ-5D-5L	2 months [median 61 days (Q1-Q3: 51 to 71 days)] after intensive care unit discharge.	Patients showed no difficulty in walking (82%), self-care (85%) and usual activities (78%). Only eight (21%) patients reported anxiety or moderate depression.	Selection (★★) Comparability (-) Exposure (★★★) Total score: 5/9	Low quality
Navarro et al., 2020	n=115 patients after mild or moderate COVID-19 [median age of 40 years (Q1-Q3: 33 to 48 years), 57.0% females, 4% admitted at intensive care unit].	To identify the changes in HRQoL in the early convalescence phase of a group of recovered COVID-19 patients.	EQ-5D-5L	1 month after the onset of symptoms.	There was a severe decrease in HRQoL in 56% of patients. Abnormalities in usual activities and anxiety/depression were detected in 59% of patients with a severe decrease in HRQoL	Selection (★★) Comparability (-) Exposure (★★★) Total score: 5/9	Low quality
Qu et al., 2021	n=540 patients with post-COVID-19, in a multicenter Chinese study, [median age of 47.50 years (Q1-Q3: 37.0 to 57 years), 50.0% females, 90.4% with mild to moderate severity].	To compare the HRQoL of patients with COVID-19 after hospital discharge with general Chinese population and to verify the determinants of HRQoL after COVID-19.	SF-36	3 months after hospital discharge.	In the post-COVID-19 patients, 15.4% had poor physical component summary, and 32.6% had poor mental component summary.	Selection (★★★) Comparability (★★) Exposure (★★★) Total score: 8/9	High quality
Rass et al., 2021	n=135 patients with post-COVID-19 [(median age of 56 days (Q1-Q3: 48 to 68 days), 61.0% males, median length of stay of 8 days (Q1-Q3: 2 to 18 days)]	To identify the impact of COVID-19 on mental health and HRQoL 3 months after disease onset.	SF-36	3 months after disease onset.	The HRQoL was impaired in 31% of patients, and symptoms of depression, anxiety, and posttraumatic stress disorders were detected in 11%, 25%, and 11% of patients, respectively.	Selection (★★) Comparability (★) Exposure (★★★) Total score: 6/9	High quality
Santus et al., 2020	n=20 hospitalized patients after COVID-19-related pneumonia (mean 55 years, SD 15, 85% males, mean length of stay 17.7 days, SD 11.5).	To assess the HRQoL of patients with post-COVID-19-related pneumonia after hospitalization.	SGRQ	15 days after hospital discharge.	After 15 days of hospital discharge, there was significant improvement in the score of all domains of SGRQ, i.e., symptoms (mean 33.7, SD 18.0 versus 16.7, SD 12.9), activity (mean 35.7, SD 24.2 versus 28.3, SD 23.3), impact (mean 17.3, SD 15.9 versus 10.6, SD 10.7), and total score (mean 25.5, SD 15.5 versus 16.9, SD 13.2) (p<0.01 for all).	Selection (★★) Comparability (-) Exposure (★★★) Total score: 5/9	Low quality
Temperoni et al., 2021	n=64 patients diagnosed with COVID-19, and aged ≤50 years (mean 41.1 years, SD 7.4, 53.8% males, 31.7% hospitalized).	To report the HRQoL of patients after COVID-19 and aged ≤50 years.	SF-36	1 month after hospital discharge.	There were no significant differences between hospitalized and non-hospitalized patients in physical or mental component summaries. The mean of SF-36 physical component summary in the hospitalized and non-hospitalized patients were, respectively, 56.25, SD 23.15 versus 55.32, SD 23.48 (p=0.894); The mean of SF-36 mental component summary in the hospitalized and non-hospitalized patients were, respectively, 53.63, SD 28.11 versus 48.72, SD 23.14 (p=0.498)	Selection (★★) Comparability (★★) Exposure (★★★) Total score: 7/9	High quality
Todt et al., 2021	n=251 patients [mean 53.6, SD 14.9 years, 59.8% males, 69.7% with severe COVID-19 at admission, 13.6% at invasive mechanical ventilation, median length of stay of 5 days (Q1-Q3: 3 to 10 days)].	To assess the impact of COVID-19 on HRQoL, anxiety, and depression after hospital discharge and to verify the determinants of the worsening in HRQoL.	EQ-5D-3L	3 months after hospital discharge	Eighty one patients had a positive screening for anxiety/depression. The EQ-5D-3L index was reduced 3 months after discharge (median score 0.80) when compared to the onset of COVID-19 symptoms (median score 1.0) (p<0.001).	Selection (★★) Comparability (★★)Exposure (★★★) Total score: 7/9	High quality
Walle-Hansen et al., 2021	n=106 participants were hospitalized for COVID-19 (mean age 74.3 years and 56.6% males, 26% after severe COVID-19).	To compare the HRQoL before and after COVID-19.	EQ-5D-5L	6 months after hospitalization	Seventy patients reported a negative change in any of the dimensions of the EQ 5D-5L when compared to before COVID-19.	Selection (★★) Comparability (★★)Exposure (★★★) Total score: 7/9	High quality

Study	Sample characteristics	Objective related to HRQoL	Instrument	Follow-up	Outcomes	Methodological quality	Overall quality
Chen et al., 2020	n=361 post-COVID-19 patients one month after hospital discharge (mean 47.22 years, SD 13.03; 51.5% males; 9.4% severe cases; mean length of stay of 19.13 days, SD 7.60 days).	To verify the difference in HRQoL between post-COVID-19 patients one month after hospital discharge and healthy Chinese individuals and to identify the determinants of HRQoL in post-COVID-19 patients	SF-36	1 month after hospital discharge	All SF-36 domains were reduced in post-COVID-19 patients when compared to the healthy Chinese population, with the exception of the score in the physical functioning domain. In the physical functioning domain, there was no difference between male post-COVID-19 patients and male Chinese general population (mean 95.13, SD 9.11 versus 95.60, SD 10.43, respectively; p=0.43), and between female post-COVID-19 patients and female Chinese general population (mean 93.17, SD 10.26 versus 92.57, SD 13.88, respectively; p=0.41).	Selection (★★★) Comparability (★) Outcome (★★) Total score: 6/10*	High quality
Gamberini et al,. 2021	n=205 patients with post-COVID-19 after intensive care unit discharge [( median age of 63 years (55 to 70 years), 74.1% males), median length of hospital stay was 42 days (Q1-Q3: 31 to 57 days).	To evaluate the HRQoL at 90 days after intensive care unit discharge and to verify the factors related to HRQoL.	15D	3 months after intensive care unit discharge	The 15D score was significantly lower in patients admitted at intensive care unit (mean 0.850, SD 0.143) than the two matched controls from Italian (mean 0.929, SD 0.809) and Finnish (mean 0.914, SD 0.084) samples of the general population (p<0.001 for both).	Selection (★★★) Comparability (★) Exposure (★★★) Total score: 7/9	High quality
Gianella et al., 2021	n=39 consecutive patients with post-COVID-19-related pneumonia [median 62.5 (Q1-Q3: 51.3 to 71.0 years; 76.9% males; median length of stay 15.0 (Q1-Q3:12.0 to 22.0 days)]	To verify the HRQoL after 3 months of follow-up and compare the HRQoL between groups with and without improvements on chest computed tomography.	SF-12 and SGRQ	3 months after hospital admission	The score evaluated by both SGRQ and SF-12 was significantly worse in post-Covid-related pneumonia patients (mean 16.97 and 30.97, respectively) when compared to the general population (reference values are 6 and 50, respectively) (p<0.0001).	Selection (★★★) Comparability (-) Exposure (★★★) Total score: 6/9	Low quality
Qu et al., 2021	n=540 patients with post-COVID-19, in a multicenter Chinese study, [median age of 47.50 years (Q1-Q3: 37.0 to 57 years), 50.0% females, 90.4% with mild to moderate severity].	To compare the HRQoL of patients with COVID-19 after hospital discharge with general Chinese population and to verify the determinants of HRQoL after COVID-19.	SF-36	3 months after hospital discharge.	The mean of SF-36 scores in the post-COVID-19 patients and in the Chinese population were, respectively: Physical functioning: 87.17, SD 14.57 versus 94.02, SD 12.44 (p<0.001); Role physical: 66.30, SD 41.04 versus 88.79, SD 28.49 (p<0.001); Bodily pain: 79.48, SD 20.73 versus 88.18, SD 19.02 (p<0.001); General heath: 68.90, SD 22.16 versus 69.74, SD 20.95 (p=0.393); Vitality: 55.35, SD 14.58 versus 68.92, SD 18.78 (p<0.001); Social functioning: 66.41, SD 24.51 versus 88.03, SD 16.00 (p<0.001); Role emotional: 71.30, SD 38.70 versus 89.57, SD 27.95 (p<0.001); Mental health: 22.86, SD 14.00 versus 77.61, SD 15.85 (p<0.001)	Selection (★★★) Comparability (★★) Exposure (★★★) Total score: 8/9	High quality
Raman et al., 2021	n=58 patients with post-COVID-19 [mean 55 years, SD 13, 59% males, median length of stay of 8.5 days (Q1-Q3: 5.0 to 17.0 days)] and 30 uninfected individuals matched for age, sex, body mass index and risk factors (smoking, diabetes and hypertension) from the community (during the same period).	To compare the HRQoL of post-COVID-19 patients with uninfected individuals.	SF-36	From 2 to 3 months from disease-onset.	The median of SF-36 scores in the post-COVID-19 patients and in uninfected individuals were, respectively: Physical functioning: 65.0, Q1-Q3: 45.0 to 90.0 versus 92.5, Q1-Q3: 83.8 to 100.0 (p<0.001); Role physical: 25.0, Q1-Q3: 0.0 to 75.0 versus 100.0, Q1-Q3: 100.0 to 100.0 (p<0.001); Role emotional: 33.3, Q1-Q3: 0.0 to 100.0 versus 100.0, Q1-Q3: 100.0 to 100.0 (p<0.001); Vitality: 45.0, Q1-Q3: 25.0 to 70.0 versus 65.0, Q1-Q3: 55.0 to 80.0 (p<0.001); Mental health: 76.0, Q1-Q3: 62.0 to 88.0 versus 84.0, Q1-Q3: 72.0 to 92.9 (p=0.044); Social functioning: 50.0, Q1-Q3: 37.5 to 87.5 versus 100.0, Q1-Q3: 62.5 to 100.0 (p<0.001); Bodily pain: 67.5, Q1-Q3: 35.0 to 90.0 versus 85.0, Q1-Q3: 67.5 to 100.0 (p=0.003); General heath: 68.8, Q1-Q3: 43.8 to 81.3 versus 75.0, Q1-Q3: 60.9 to 87.5 (p=0.022).	Selection (★★★) Comparability (★★) Exposure (★★★) Total score: 8/9	High quality
van der Sar-van der Brugge et al., 2021	n=101 participants after COVID-19-related pneumonia (mean 66.4 years, SD 12.6, 57.4% males, 72.3% after severe pneumonia).	To compare the HRQoL of patients after COVID-19-related pneumonia with the general Dutch population.	SF-36	6 weeks after hospital discharge.	When compared to general Dutch population, impaired HRQoL was found in almost all domains of the SF-36, except for bodily pain. The domains with the greatest commitment were physical role limitation, physical functioning and vitality.	Selection (★★) Comparability (★★) Exposure (★★★) Total score: 7/9	High quality

Study	Sample characteristics	Objective related to HRQoL	Instrument	Follow-up	Outcomes	Methodological quality	Overall quality
Albu et al., 2021	n=30 individuals with persistent symptoms and/or sequelae of COVID-19 (16 post-intensive care unit, median age of 54 years (Q1-Q3: 43.8 to 62.0 years), 61.2% males, median length of hospital stay of 37 days (Q1-Q3: 15 to 69 days).	The compare the HRQoL of post-COVID-19 patients that were admitted ate intensive care unit with those that who not and to verify the correlation between HRQoL and fatigue and anxiety/depression.	WHOQOL-Bref	>3 months after acute COVID-19	There were no differences between groups admitted at post-intensive care unit and without post-intensive care unit in any WHOQOL-Bref domain.	Selection (★★★) Comparability (★★) Outcome (★★) Total score: 7/10*	High quality
Halpin et al., 2020	n=100 patients post-COVID-19, divided into ward group [68 patients; median age of 70.5 years (Q1-Q3: 20 to 93 years), 51.5% males; median length at ward of 6.5 days (Q1-Q3: 4 to 14)] and ICU group [(32 patients; median age of 58.5 years; 59.4% males; median length at intensive care unit of 4 days (Q1-Q3: 2.6 to 5.7 days).	To identify the impact of COVID-19 on HRQoL of discharged survivors.	EQ-5D-5L	Between 4 to 8 weeks after discharge	There was a clinically significant drop in EQ5D by 68.8% in the intensive care unit group and 45.6% in the ward group.	Selection (★★★) Comparability (★) Outcome (★★) Total score: 5/10*	High quality
Garrigues et al., 2020	n=120 patients post-COVID-19 stratified into ward group [96 patients; mean 64.1 years, SD 16.1), 58.3% males; mean length of stay in hospital 7.4 days, SD 5.4, and intensive care unit group (24 patients; mean 59.6 years, SD 13.7; 79.2% males; mean length of stay in hospital 26.5 days, SD 22.3).	To verify the difference in HRQoL between patients admitted at ward and at intensive care unit.	EQ-5D-5L	Mean of 110.9 days after admission for COVID-19.	There was no difference in HRQoL between group admitted at ward versus intensive care unit both in EQ-5D-5L (mean score 0.86, SD 0.19 versus 0.82, SD 0.21, respectively; p=0.306), and Visual analogic scale (mean score 69.9, SD 21.4 versus 71.7, SD 22.2, respectively; p=0.711).	Selection (★★★) Comparability (★★) Outcome (★★) Total score: 7/10*	High quality
Huang et al., 2021	n=1733 patients after hospital discharge from COVID-19; median 57.0 years (Q1-Q3: 47.0 to 65.0 years; median length of stay of 14.0 (Q1-Q3: 10.0 to 19.0 days), 52% men. Patients were stratified into three groups: that did not require oxygen supplementation; that required oxygen supplementation; and that required high-flow nasal cannula, or non-invasive mechanical ventilation, or invasive mechanical ventilation.	To verify the difference in HRQoL among the three groups of patients.	EQ-5D-5L	Median 186.0 (Q1-Q3: 175.0 to 199.0) days.	When compared to patients that did not require supplemental oxygen, patients with high-flow nasal cannula, non-invasive mechanical ventilation, or invasive mechanical ventilation had more problems in mobility (6% versus 14%), pain or discomfort (26% versus 41%), and anxiety or depression (23% versus 32%).	Selection (★★) Comparability (★★) Exposure (★★★) Total score: 7/9	High quality
Lerum et al., 2021	n=103 patients post- COVID-19, stratified in group after intensive care unit [n=15, median age 52 years (Q1-Q3: 50 to 59 years; 73% males; median length of stay 17 days (Q1-Q3: 12 to 25 years)] and no intensive care unit [n=88; median age 61 years (Q1-Q3: 49 to 74 years; 49% males, median length of stay 5.0 (Q1-Q3: 3 to 9 days)]	To verify the difference in HRQoL between patients with and without admission at the intensive care unit.	EQ-5D-5L	3 months after hospital discharge	Patients admitted to the intensive care unit (median score 4, Q1-Q3: 2 to 4) had worse HRQoL in the domain usual activities than patients admitted only to regular wards (median score 2, Q1-Q3: 1 to 2, respectively) (p=0.014).	Selection (★★) Comparability (★) Exposure (★★★) Total score: 6/9	High quality

Study	Sample characteristics	Objective related to HRQoL	Instrument	Follow-up	Outcomes	Methodological quality	Overall quality
Albu et al., 2021	n=30 individuals with persistent symptoms and/or sequelae of COVID-19 (16 post-intensive care unit, median age of 54 years (Q1-Q3: 43.8 to 62.0 years), 61.2% males, median length of hospital stay of 37 days (Q1-Q3: 15 to 69 days).	The compare the HRQoL of post-COVID-19 patients that were admitted ate intensive care unit with those that who not and to verify the correlation between HRQoL and fatigue and anxiety/depression.	WHOQOL-Bref	>3 months after acute COVID-19	In general, HRQoL correlated with the impact of fatigue and anxiety/depression, except for the environment domain.	Selection (★★★) Comparability (★★) Outcome (★★) Total score: 7/10*	High quality
Anastasio et al., 2021	n=379 patients after the diagnosis of COVID-19, [median age of 56 years old (Q1-Q3: 49 to 63), 45.9% males, 222 after pneumonia, 161 without acute respiratory distress syndrome and 61 after acute respiratory distress syndrome].	To correlate the physical and mental component summaries of the SF-12 with lung function, development of pneumonia, acute respiratory distress syndrome, invasive mechanical ventilation, partial oxygen saturation/fraction of inspired oxygen ratio or pneumonia severity index.	SF-12	4 months after COVID-19 diagnosis	There was no significant correlation between physical or mental component summary with lung function, development of pneumonia, acute respiratory distress syndrome, invasive mechanical ventilation, partial oxygen saturation/fraction of inspired oxygen ratio or pneumonia severity index.	Selection (★★) Comparability (-) Exposure (★★★) Total score: 5/9	Low quality
Arab-Zozani et al., 2020	n=409 post-COVID-19 patients, mean 58.4 years, SD 18.21, 60.27% males, mean length of hospital stay 8 days, SD 7.	To verify the determinants of HRQoL	EQ-5D-5L	Mean 21.6 days, SD 14.8	Female sex, age> 50 years, university degree, be unemployed, presence of diabetes, diagnosis of heart failure, and admission to the intensive care unit were independent determinants of the HRQoL.	Selection (★★★) Comparability (★★) Outcome (★★) Total score: 7/10*	High quality
Chen et al., 2020	n=361 post-COVID-19 patients one month after hospital discharge (mean 47.22 years, SD 13.03; 51.5% males; 9.4% severe cases; mean length of stay of 19.13 days, SD 7.60).	To verify the difference in HRQoL between post-COVID-19 patients one month after hospital discharge and healthy Chinese individuals and to identify the determinants of HRQoL in post-COVID-19 patients	SF-36	1 month after hospital discharge	Factors associated HRQoL in post-COVID-19 patients were age, female sex, clinical subtype of the disease, chronic kidney disease, length of stay, smoking history and forced vital capacity. The determinants of lower physical component scores were overweight and obesity. The determinant of the mental component was female sex.	Selection (★★★) Comparability (★) Outcome (★★) Total score: 6/10*	High quality
Gamberini et al., 2021	n=205 patients with post-COVID-19 after intensive care unit discharge [(median age of 63 years (55 to 70 years), 74.1% males), median length of hospital stay was 42 days (Q1-Q3: 31 to 57 days).	To evaluate the HRQoL at 90 days after intensive care unit discharge and to verify the factors related to HRQoL.	15D	3 months after intensive care unit discharge	Age, female sex, number of comorbidities, acute respiratory distress syndrome class, duration of invasive mechanical ventilation, and occupational status were found to be significant determinants of the 90 days HRQoL. Clinical severity at admission was poorly correlated to HRQoL.	Selection (★★★) Comparability (★) Exposure (★★★) Total score: 7/9	High quality
Gianella et al., 2021	n=39 consecutive patients with post-COVID-19-related pneumonia [median 62.5 (Q1-Q3: 51.3 to 71.0 years; 76.9% males; median length of stay 15.0 (Q1-Q3:12.0 to 22.0 days)]	To verify the HRQoL after 3 months of follow-up and compare the HRQoL between groups with and without improvements on chest computed tomography.	SF-12 and SGRQ	3 months after hospital admission	After 3 months, there was no difference in SF-12 and SGRQ score between those who improved the chest computed tomography scan and those who did not (p>0.05). The median of SF-12 scores in the post-COVID-19 patients who improved the chest computed tomography scan and those who did not were, respectively: Physical domain: 53.1, Q1-Q3: 41.9 to 56.0 versus 32.5, Q1-Q3: 28.9 to 52.5 (p=0.051); and mental domain: 57.5, Q1-Q3: 49.0 to 59.9 versus 53.1, Q1-Q3: 41.4 to 58.9 (p=0.64). The median of SGRQ scores in the post-COVID-19 patients who improved the chest computed tomography scan and those who did not were, respectively, 9.9, Q1-Q3: 7.2 to 16.2 versus 20.4, Q1-Q3: 8.1 to 50.5 (p=0.16)	Selection (★★★) Comparability (-) Exposure (★★★) Total score: 6/9	Low quality
Lindahl et al., 2021	n=54 male patients (mean 60 years, SD 11, mean length of hospital stay 18 days, SD 17) and 47 female patients (mean 59 years, SD 11, mean length of hospital stay 12 days, SD 8)	To verify the determinants of HRQoL in patients with post-COVID-19 after hospitalization.	RAND-36	6 months	Age, female sex, BMI, sleep apnoea, and duration of mechanical ventilation were associated with worse HRQoL.	Selection (★★★) Comparability (★★) Outcome (★★) Total score: 7/10*	High quality
Qu et al., 2021	n=540 patients with post-COVID-19, in a multicenter Chinese study [median age of 47.50 years (Q1-Q3: 37.0 to 57 years), 50.0% females, 90.4% with mild to moderate severity].	To compare the HRQoL of patients with COVID-19 after hospital discharge with general Chinese population and to verify the determinants of HRQoL after COVID-19.	SF-36	3 months after hospital discharge.	Female sex, older age (≥ 60 years) and physical symptoms were associated with poor physical component summary; the physical symptom after discharge was associated with poor mental component summary.	Selection (★★★) Comparability (★★) Exposure (★★★) Total score: 8/9	High quality
Todt et al., 2021	n=251 patients [mean 53.6 years, SD 14.9, 59.8% males, 69.7% with severe COVID-19 at admission, 13.6% at invasive mechanical ventilation, median length of stay of 5 days (Q1-Q3: 3 to 10 days)].	To assess the impact of COVID-19 on HRQoL, anxiety, and depression after hospital discharge and to verify the determinants of the worsening in HRQoL.	EQ-5D-3L	3 months after hospital discharge	Only female sex and intensive care requirement were independently associated with worsening of HRQoL.	Selection (★★) Comparability (★★) Exposure (★★★) Total score: 7/9	High quality

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[1] Corresponding author: Dr. Henrique Silveira Costa. e-mail:henriquesilveira@yahoo.com.br