ArticlePloS one2025
Classifying COVID-19 hospitalizations in epidemiology cohort studies: The C4R study.
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Article in PloS one, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers.
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5citing papers in PubMed
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Who cites it
5 citing papers in PubMed.
- Associations of Pre-Pandemic CKD With Acute and Post-Acute COVID-19: The C4R Study.American journal of kidney diseases : the official journal of the National Kidney Foundation · 2026Article
- COVID-19-Related Immune Activation and Capsular Contracture: A Cohort Study of Infection, Vaccination, and Explantation.Aesthetic plastic surgery · 2026Article
- Life's Essential 8 and Risk of Severe COVID-19 Among Adults Without Clinical Cardiovascular Disease: The C4R Study.Journal of the American Heart Association · 2026Article
- Spatial and neighborhood data in the collaborative cohort of cohorts for COVID-19 Research (C4R).PloS one · 2026Observational
- Associations of Prepandemic Lung Function and Structure with COVID-19 Outcomes: The C4R Study.American journal of respiratory and critical care medicine · 2025Article
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Authors and funding
61 authors.
Elizabeth C OelsnerDivision of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America.ORCID 0000-0002-7481-9671
Akshaya KrishnaswamyDivision of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America.
Rafail RustamovDepartment of Medicine, Nassau University Medical Center, East Meadow, New York, United States of America.ORCID 0009-0004-0035-1481
Pallavi P BalteDivision of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America.
Tauqeer AliCenter for American Indian Health Research, Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America.
Norrina B AllenCenter for Epidemiology and Population Health, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, United States of America.
Howard F AndrewsData Coordinating Center and Biostatistics Department, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, United States of America.
Pramod AnuguDepartment of Medicine University of Mississippi Medical Center, Jackson, Mississippi, United States of America.
Alexander ArynchynDivision of General Internal Medicine and Population Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.
Lori A BatemanCollaborative Studies Coordinating Center, Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
Jianwen CaiCollaborative Studies Coordinating Center, Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
Harry ChangDivision of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America.
Lucas ChenNHLBI's Framingham Heart Study, Framingham, Massachusetts, United States of America.
Mitchell S V ElkindDepartment of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America.ORCID 0000-0003-2562-1156
James S FloydDepartment of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America.
Kelley Pettee GabrielDepartment of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.
Sina A GharibDivision of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, United States of America.
Jose D GutierrezDepartment of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America.
Karen Hinckley StukovskyDepartment of Biostatistics, School of Public Health, University of Washington, Seattle, Washington, United States of America.
Virginia J HowardDepartment of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.
Carmen R IsasiDepartment of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America.
Lauren JagerDepartment of Biostatistics, School of Public Health, University of Washington, Seattle, Washington, United States of America.
Ling JinNHLBI's Framingham Heart Study, Framingham, Massachusetts, United States of America.
Suzanne E JuddDepartment of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.ORCID 0000-0001-7594-6587
Alka M KanayaDepartment of Medicine, University of California San Francisco, San Francisco, California, United States of America.
Namratha R KandulaCenter for Epidemiology and Population Health, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, United States of America.
Maureen R KellyDivision of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America.
Sadiya S KhanDivision of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois, United States of America.
Anna Kucharska-NewtonDepartment of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.ORCID 0000-0001-9864-467X
Joyce S LeeDivision of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America.
Emily B LevitanDepartment of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.
Cora E LewisDepartment of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.ORCID 0000-0002-2301-5796
Barry J MakeDivision of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado, United States of America.
Kimberly MalloyCenter for American Indian Health Research, Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America.
Jennifer J ManlyDepartment of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America.
David MaugerDivision of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, State College, Pennsylvania, United States of America.
Yuan-I MinDepartment of Medicine University of Mississippi Medical Center, Jackson, Mississippi, United States of America.
Joanne M MurabitoNHLBI's Framingham Heart Study, Framingham, Massachusetts, United States of America.
Charles G MurphyDivision of Pulmonary Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, New York, United States of America.
Arnita F NorwoodDepartment of Medicine University of Mississippi Medical Center, Jackson, Mississippi, United States of America.ORCID 0000-0001-5897-3436
George T O'ConnorNHLBI's Framingham Heart Study, Framingham, Massachusetts, United States of America.
Victor E OrtegaDivision of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Department of Medicine, Mayo Clinic Scottsdale, Scottsdale, Arizona, United States of America.
Ashmi A PatelDivision of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America.
Amber PirzadaInstitute for Minority Health Research, University of Illinois Chicago, Chicago, Illinois, United States of America.
Elizabeth A ReganDivision of Rheumatology, Department of Medicine, National Jewish Health, Denver, Colorado, United States of America.
Kimberly B RingCollaborative Studies Coordinating Center, Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
Wayne D RosamondDepartment of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
David A SchwartzDivision of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America.
James M ShikanyDivision of General Internal Medicine and Population Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.ORCID 0000-0002-2424-9308
Daniela Sotres-AlvarezCollaborative Studies Coordinating Center, Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
Cheryl TarltonCenter for American Indian Health Research, Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America.
Janis TseNHLBI's Framingham Heart Study, Framingham, Massachusetts, United States of America.
Elman M Urbina MenesesDivision of Pulmonary and Critical Care, Graduate School of Medicine, University of Tennessee, Knoxville, Tennessee, United States of America.
Maya VankineniDivision of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America.
Sally E WenzelDepartment of Environmental and Occupational Health, School of Public Heath, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.
Prescott G WoodruffDivision of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America.
Vanessa XanthakisNHLBI's Framingham Heart Study, Framingham, Massachusetts, United States of America.
Ji Hyun YangNHLBI's Framingham Heart Study, Framingham, Massachusetts, United States of America.
Neil A ZakaiDepartment of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, United States of America.
Ying ZhangCenter for American Indian Health Research, Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America.
Wendy S PostDivision of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America.
Funding
ACTIV Integration of Host-targeting Therapies for COVID-19 Administrative Coordinating CenterOT2HL156812 · NHLBI · RESEARCH TRIANGLE INSTITUTE · PI NOLEN, TRACY L, THOMAS, SONIA M · 2020 to 2024
$1270.7MUCSF CLINICAL AND TRANSLATIONAL SCIENCE INSTITUTEUL1RR024131 · NCRR · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · PI JOHNSTON, S. CLAIBORNE · 2006 to 2011
$111.2MVCID and Stroke in a Bi-racial National CohortU01NS041588 · NINDS · UNIVERSITY OF ALABAMA AT BIRMINGHAM · PI CUSHMAN, MARY, HOWARD, GEORGE · 2002 to 2022
$96.0MARIC Neurocognitive Study (ARIC-NCS) Renewal 2023-2028U01HL096812 · NHLBI · NEW YORK UNIVERSITY SCHOOL OF MEDICINE · PI JOSEF CORESH, THOMAS H MOSLEY · 2010 to 2026
$65.7MInstitute for Clinical and Translational ResearchUL1TR001079 · NCATS · JOHNS HOPKINS UNIVERSITY · PI FORD, DANIEL ERNEST · 2013 to 2017
$60.1MGenetic Epidemiology of COPDU01HL089897 · NHLBI · NATIONAL JEWISH HEALTH · PI CRAPO, JAMES D · 2007 to 2021
$56.9MSubclinical Vascular Contributions to Alzheimer's Disease: The Multi-Ethnic Study of Atherosclerosis (MESA) Multisite Study of AD (Renewal)R01AG058969 · NIA · WAKE FOREST UNIVERSITY HEALTH SCIENCES · PI Timothy M. Hughes, YONGMEI LIU · 2018 to 2026
$33.4MWake Forest Clinical and Translational Science AwardUL1TR001420 · NCATS · WAKE FOREST UNIVERSITY HEALTH SCIENCES · PI ARD, JAMY D, FOLEY, KRISTIE L · 2015 to 2023
$32.3MFRAMINGHAM HEART STUDY - YEAR 5 EXAM75N92019D00031 · NHLBI · BOSTON UNIVERSITY MEDICAL CAMPUS · PI RAMACHANDRAN, VASAN · 2019 to 2024
$29.8MSPIROMICS II: Biological underpinnings of COPD heterogeneity and progressionU01HL137880 · NHLBI · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · PI WOODRUFF, PRESCOTT G · 2017 to 2021
$27.9MClinical and Translational Science AwardUL1TR000040 · NCATS · COLUMBIA UNIVERSITY HEALTH SCIENCES · PI GINSBERG, HENRY N · 2012 to 2015
$26.2MMechanisms of Familial Pulmonary FibrosisP01HL092870 · NHLBI · VANDERBILT UNIVERSITY MEDICAL CENTER · PI BLACKWELL, TIMOTHY S. · 2010 to 2020
$21.6MIntramural NIH HHS Z01 ES101947NCATS NIH HHS UL1 TR000040NCATS NIH HHS UL1 TR001079NCATS NIH HHS UL1 TR001420NCRR NIH HHS UL1 RR024131NHLBI NIH HHS 75N92019D00027NHLBI NIH HHS 75N92019D00028NHLBI NIH HHS 75N92019D00029NHLBI NIH HHS 75N92019D00030NHLBI NIH HHS 75N92019D00031NHLBI NIH HHS 75N92020D00001NHLBI NIH HHS 75N92020D00002NHLBI NIH HHS 75N92020D00003NHLBI NIH HHS 75N92020D00004NHLBI NIH HHS 75N92020D00005NHLBI NIH HHS 75N92020D00006NHLBI NIH HHS 75N92020D00007NHLBI NIH HHS 75N92022D00001NHLBI NIH HHS 75N92022D00002NHLBI NIH HHS 75N92022D00003NHLBI NIH HHS 75N92022D00004NHLBI NIH HHS 75N92022D00005NHLBI NIH HHS 75N92023D00002NHLBI NIH HHS 75N92023D00003NHLBI NIH HHS 75N92023D00004NHLBI NIH HHS 75N92023D00005NHLBI NIH HHS 75N92023D00006NHLBI NIH HHS HHSN268200900013CNHLBI NIH HHS HHSN268200900014CNHLBI NIH HHS HHSN268200900015CNHLBI NIH HHS HHSN268200900016CNHLBI NIH HHS HHSN268200900017CNHLBI NIH HHS HHSN268200900018CNHLBI NIH HHS HHSN268200900019CNHLBI NIH HHS HHSN268200900020CNHLBI NIH HHS HHSN268201500001CNHLBI NIH HHS HHSN268201500001INHLBI NIH HHS HHSN268201500003CNHLBI NIH HHS HHSN268201500003INHLBI NIH HHS HHSN268201800010INHLBI NIH HHS HHSN268201800011CNHLBI NIH HHS HHSN268201800011INHLBI NIH HHS HHSN268201800012CNHLBI NIH HHS HHSN268201800012INHLBI NIH HHS HHSN268201800014CNHLBI NIH HHS HHSN268201800014INHLBI NIH HHS HHSN268201800015INHLBI NIH HHS K23 HL130627NHLBI NIH HHS N01 HC025195NHLBI NIH HHS N01 HC065233NHLBI NIH HHS N01 HC065234NHLBI NIH HHS N01 HC065235NHLBI NIH HHS N01 HC065236NHLBI NIH HHS N01 HC065237NHLBI NIH HHS N01 HC095159NHLBI NIH HHS N01 HC095160NHLBI NIH HHS N01 HC095161NHLBI NIH HHS N01 HC095162NHLBI NIH HHS N01 HC095163NHLBI NIH HHS N01 HC095164NHLBI NIH HHS N01 HC095165NHLBI NIH HHS N01 HC095166NHLBI NIH HHS N01 HC095167NHLBI NIH HHS N01 HC095168NHLBI NIH HHS N01 HC095169NHLBI NIH HHS OT2 HL156812NHLBI NIH HHS P01 HL092870NHLBI NIH HHS R01 HL077612NHLBI NIH HHS R01 HL080477NHLBI NIH HHS R01 HL093009NHLBI NIH HHS R01 HL093081NHLBI NIH HHS R01 HL095393NHLBI NIH HHS R01 HL097163NHLBI NIH HHS R01 HL098433NHLBI NIH HHS R01 HL101250NHLBI NIH HHS R01 HL109282NHLBI NIH HHS R01 HL109284NHLBI NIH HHS R01 HL109301NHLBI NIH HHS R01 HL109315NHLBI NIH HHS R01 HL109319NHLBI NIH HHS R01 HL127028NHLBI NIH HHS R01 HL127659NHLBI NIH HHS R01 HL130506NHLBI NIH HHS R01 HL135009NHLBI NIH HHS R01 HL165452NHLBI NIH HHS R21 HL120770NHLBI NIH HHS R21 HL121457NHLBI NIH HHS R21 HL129924NHLBI NIH HHS R21 HL153700NHLBI NIH HHS R33 HL120770NHLBI NIH HHS U01 HL041642NHLBI NIH HHS U01 HL041652NHLBI NIH HHS U01 HL041654NHLBI NIH HHS U01 HL065520NHLBI NIH HHS U01 HL065521NHLBI NIH HHS U01 HL089856NHLBI NIH HHS U01 HL089897NHLBI NIH HHS U01 HL096812NHLBI NIH HHS U01 HL096814NHLBI NIH HHS U01 HL096899NHLBI NIH HHS U01 HL096902NHLBI NIH HHS U01 HL096917NHLBI NIH HHS U01 HL137880NHLBI NIH HHS U10 HL109086NHLBI NIH HHS U10 HL109146NHLBI NIH HHS U10 HL109152NHLBI NIH HHS U10 HL109164NHLBI NIH HHS U10 HL109168NHLBI NIH HHS U10 HL109172NHLBI NIH HHS U10 HL109250NHLBI NIH HHS U10 HL109257NHLBI NIH HHS U24 HL141762NHLBI NIH HHS UG3 HL151865NHLBI NIH HHS UH2 HL123442NHLBI NIH HHS UH3 HL123442NIA NIH HHS R01 AG058969NIA NIH HHS R01 AG066162NIMHD NIH HHS HHSN268201800013ININDS NIH HHS R01 NS029993NINDS NIH HHS R01 NS048134NINDS NIH HHS U01 NS041588
Abstract
rationaleRobust COVID-19 outcomes classification is important for ongoing epidemiology research on acute and post-acute COVID-19 conditions. Protocolized medical record review is an established method to validate endpoints for clinical trials and cardiovascular epidemiology cohorts; however, a protocol to adjudicate hospitalizations for COVID-19 among epidemiology cohorts was lacking.
objectivesWe developed a protocol to ascertain and adjudicate hospitalized COVID-19 across a meta-cohort of 14 US prospective cohort studies. This report describes the first three years of protocol implementation (October 1, 2020-October 1, 2023) and evaluates its repeatability and performance compared to classification by administrative codes.
methodsThe protocol was adapted from cohort approaches to clinical cardiovascular events ascertainment and adjudication. Potential COVID-19 hospitalizations and deaths were identified by self-/proxy-report and, in some cases, active surveillance. Medical records were requested from hospitals and adjudicated for COVID-19 outcomes by clinically trained personnel according to a standardized rubric. Inter-rater agreement was assessed. The sensitivity and specificity of discharge diagnosis codes was compared to adjudicated diagnoses. MEASUREMENTS AND MAIN
resultsThe study obtained medical records for 1,167 potential COVID-19 hospitalizations, which underwent protocolized adjudication. Adjudication confirmed COVID-19 infection was present for 1,030 (88%) events, of which COVID-19 was not the cause of hospitalization for 78 (8%). Of 952 hospitalizations determined by adjudicators to be caused by COVID-19, 319 (34%) participants were critically ill and 210 (22%) died. Pneumonia was confirmed in 822 (86%) and acute kidney injury in 350 (37%); other cardiovascular and thrombotic complications were rare (2-5%). Interrater reliability among adjudicators was high (kappa = 0.85-1.00) except for myocardial infarction (kappa = 0.60). Compared to adjudication, sensitivity of discharge diagnosis codes was higher for pneumonia (84%) and pulmonary embolism (81%) than for other complications (48-70%).
conclusionsProtocolized adjudication confirmed four out of five COVID-19 hospitalizations in a US meta-cohort and confirmed cases of pneumonia, pulmonary embolism, and other conditions that were not indicated by discharge diagnosis codes. These results highlight the importance of validating health outcomes for use in research on COVID-19 and post-COVID-19 conditions, and some limitations of claims-based data.
Indexed as
COVID-19HospitalizationAdultAgedCohort StudiesFemaleHumansMaleMiddle AgedProspective StudiesSARS-CoV-2United States
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