Another way to approach post-COVID syndrome. From functionality to the symptoms.

Dear Director:

Based on its prevalence, impact on quality of life, and use of resources, no one can question the importance of the set of symptoms that a large number of patients report experiencing following acute SARS-CoV-2 infection. This importance is accompanied by an outpouring of publications concurring on the lack of agreement regarding very basic aspects such as the definition of a entity which, for the sake of simplicity, we will call post-COVID condition (PCC)2, 3, 4, 5 and which the World Health Organization (WHO) defines as a “set of symptoms that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually three months from the onset of COVID-19 with symptoms that last for at least two months and cannot be explained by an alternative diagnosis and which generally have an impact on everyday functioning”.

With this as our context, we have read with interest the document titled “Protocol for ongoing care for patients with a COVID-19 diagnosis” (SEMI-SEMERGEN) from our own society, the Spanish Society of Internal Medicine (SEMI), and the Spanish Society of Primary Care Physicians (SEMERGEN). It is important to highlight the aim of the document, which is to help coordinate between the various levels of care, as this had not yet been previously addressed in such a clear7, 8 and essential manner, as both patients who required hospitalisation, as well as those who did not, can develop PCC2, 3, 4, 5.

As with acute COVID-19, inter-individual heterogeneity is the general rule of PCC: over 200 manifestations have been reported with an average of 36 per patient. Some manifestations persist beyond the acute phase, or new onset symptoms may appear, making it a condition that is difficult to categorise. These may also be accompanied by sequelae from the acute phase or those resulting from the actual hospitalisation, such as those of a nutritional and psychological nature. It also features a poorly characterised set of symptoms due to non-specific fatigue, bradyphrenia, pain and an extensive list that mimics fibromyalgia/chronic fatigue syndrome that seems to be rooted in a sustained inflammatory response.

This is usually in addition to the uncertainty created by a discrepancy between the patient’s condition and the typically normal results of additional testing. Regarding the relevance of psychological factors, one study showed for the French population that a large percent of patients attributed their current symptomatology, the basis of their consultation, to a previous case of COVID-19, even in the absence of microbiological evidence of infection.

A document such as that from the SEMI/SEMERGEN is a highly necessary tool as both patient and physician are faced with a great deal of uncertainty. However, we would like to offer an assessment as the basis for a proposal that we consider to be different to those available in the literature, including the protocol mentioned here6, 7, 8. These publications tend to propose addressing each one of the patient-reported manifestations, thus establishing specific circuits for the evaluation of each symptom. The complexity of this approach is obvious, as it leads to an endless number of appointments and tests as well as pharmacological approaches that rarely end up benefiting the patient.

Unlike the “symptom by symptom” approach, in our Health Department we have developed a protocol between the Primary Care (PC) and Specialised Care services. We sought to simplify the approach by evaluating impact on function prior to the acute infection rather than assessing manifestations one at a time, with the understanding that those manifestations that had not impacted function/quality of life were not relevant and, therefore, would not benefit from a proactive approach.

According to this approach, in a series of 150 patients evaluated between 4 and 12 weeks post-acute COVID-19, cardiac sequelae were found in one fourth of the cases, findings that were correlated with worse quality of life and function as measured by the EQ-5D-5L QoL and PCFS scales. For the sake of simplicity, we based the evaluation on validated, self-administered scales conducted during in-person or telephone appointments. The use of validated scales is likely an added value for the more complex, non-validated telephone consult check list from the SEMI/SEMERGEN document which is based on the clinical experience of a single centre.

These scales enable objective progress to be made in the three steps on which the protocol is based, and which consecutively seek to continue responding to the three questions that guide clinicians during evaluation (Fig. 1 ). Three questions whose aim is to determine: first whether relevant global functional involvement exists, then if there is any pulmonary involvement, and lastly to look for any conditions other than those that are strictly pulmonary. As we can only look at the symptoms, a second contribution to the protocol could be therapeutic action rooted in physiotherapy measures and active clinician follow-up, as creating a reasonable degree of certainty is essential for patients with this condition.

Figure 1

Multidisciplinary follow-up protocol diagram for patients with suspected PCC from the San Juan de Alicante Health Department (Alicante).

1 min STST: 1 min Sit-To-Stand Test; GLIM: Global Leadership Initiative on Malnutrition criteria; mMRC: Modified Medical Research Council Scale; NEUR: neurology; PCC: post-COVID condition; PCFS: Post-COVID-19 Functional Scale; PFT: pulmonary function test; PSY: psychiatry; PULM: pulmonology; REHAB: rehabilitation; RHU: rheumatology; SC: systemic corticosteroids; X-ray: simple radiography.

Lastly, bearing in mind the health care burden that monitoring all infected individuals entails, determining which subjects are benefiting from intervention is of utmost importance. Therefore, in line with the SEMI/SEMERGEN proposal, this promotes a model of care that is based on the risk factors with the most evidence of developing PCC, such as: severity of the initial infection, age, and comorbidities. The latter two aspects are summarized in the presented model as classifying patients as complex and chronic. However, in our opinion, these criteria are very general and non-specific and, while it may seem logical to apply said criteria to patients who required hospitalisation, they are likely to be impractical for screening patients seen in a Primary Care setting. Therefore, as a third criteria of severity, we stipulated that at least 6 of the following symptoms had to be present during the first week of acute infection: headache, fever, asthenia, cough, dyspnoea, diarrhoea, rhinorrhoea, ageusia and/or anosmia, myalgia and chest pain. According to this risk classification, we determine whether follow-up should occur via PC or Specialised Care and whether this should be in-person or over the phone (Fig. 2 ).

Figure 2

Follow-up according to the risk of developing PCC whether the patient was hospitalised during the acute phase.

CC: chronic complex patient; HFO: high flow oxygen; ICU: intensive care unit; INTMED: internal medicine; NIMV: non-invasive mechanical ventilation; PC: primary care; PCS: post-COVID syndrome; PULM: Pulmonology; X-ray: simple chest radiography.

* Headache, fever, asthenia, cough, dyspnoea, diarrhoea, rhinorrhoea, nausea or vomiting, anosmia or ageusia, myalgia, chest pain.

** Patient requiring supplementary O2 during admission for COVID-19 other than high flow oxygen therapy or non-invasive mechanical ventilation.

PCFS scale (post-COVID Functional Scale).

We hope that our commentary contributes to the creation of a unified guideline that standardises and ensures ongoing care for patients with PCC and steers away from the complexity of other models that have, on occasion, resulted in the decline of the affected individuals due to exhaustive analysis of symptoms in place of the ultimate functional consequences to the individual.