Re: Fresh evidence of the scale and scope of long covid
Dear Editor
In reference to the commentary by Sivan, Ranyer and Delaney “The NHS must reconfigure services to manage enduring multimorbidity following covid-19” the challenges maybe even greater than those described. Certainly, breaking down the tendency for physicians to focus on the system in which they have developed particular expertise is important. Teams with a high proportion of therapists and medical staff willing and able to address symptoms related to multiple systems will be essential. The ‘guiding hand’ that is often absent when patients attend multiple clinics separately to discuss uncoordinated management plans will need to be both visible and effective. An additional skillset will include familiarity with ‘functional’ or medically unexplained symptoms. Although Ayoubkhani et al’s study showed a high prevalence of new post-covid diagnoses (e.g. diabetes, kidney disease, cardiovascular events), early experience does suggest that symptoms may be disproportionate to observable organ dysfunction in up to 30% of patients [1] [2]. A large Chinese study found that the main symptoms were fatigue, muscle weakness, sleep difficulties, and anxiety/depression [3]. Few system-based specialists are equipped to help with these. Although there is increasing evidence that subtle chemical and biological changes do underpin many functional conditions, physicians are often quick to discharge patients from the clinic back to primary care with advice once one has been diagnosed [4][5]. This will not suffice for patients with post-covid-19 syndrome.
Beyond clinical skills, the existing economic model may need to be altered. Currently, secondary care clinics look for ways to reduce their new-to-follow up ratios by discharging patients after one or two visits. There are significant financial incentives for such ‘quick turnarounds’, as payment to providers is not proportionate to the number of attendances or investigations. This arrangement comes under a ‘payment by results’ (PBR) model, but this is not the same as ‘payment by outcomes’. The financial transaction is not related to ultimate cure or improvement. In this new and challenging area of medicine where achievable clinical outcomes are still poorly understood, subjective improvement in symptom burden should to be a key marker of successful management. Formal use of patient reported outcome measures (PROMs) remains poorly developed in primary and secondary care, despite their collection by providers since 2009 [6]. If there was ever a condition where their use should be prioritised, and traditional economic models challenged, it is post-covid-19.
1. Ayoubkhani D, Khunti K, Nafilyan V, Maddox T, Humberstone B, Diamond I, Banerjee A. Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ. 2021 Mar 31;372:n693
2. Dennis A, Wamil M, Alberts J, Oben J, Cuthbertson DJ, Wootton D, Crooks M, Gabbay M, Brady M, Hishmeh L, Attree E, Heightman M, Banerjee R, Banerjee A; COVERSCAN study investigators. Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: a prospective, community-based study. BMJ Open. 2021 Mar 30;11(3):e048391.
3. Huang C, Huang L, Wang Y, Li X, Ren L, Gu X, Kang L, Guo L, Liu M, Zhou X, Luo J, Huang Z, Tu S, Zhao Y, Chen L, Xu D, Li Y, Li C, Peng L, Li Y, Xie W, Cui D, Shang L, Fan G, Xu J, Wang G, Wang Y, Zhong J, Wang C, Wang J, Zhang D, Cao B. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021 Jan 16;397(10270):220-232.
4. Bransfield RC, Friedman KJ. Differentiating Psychosomatic, Somatopsychic, Multisystem Illnesses, and Medical Uncertainty. Healthcare (Basel). 2019 Oct 8;7(4):114.
5. Ng QX, Soh AYS, Loke W, Lim DY, Yeo WS. The role of inflammation in irritable bowel syndrome (IBS). J Inflamm Res. 2018 Sep 21;11:345-349.
6. Timmins N. NHS goes to the PROMS. BMJ. 2008 Jun 28;336(7659):1464-5.
Rapid Response:
Re: Fresh evidence of the scale and scope of long covid
Dear Editor
In reference to the commentary by Sivan, Ranyer and Delaney “The NHS must reconfigure services to manage enduring multimorbidity following covid-19” the challenges maybe even greater than those described. Certainly, breaking down the tendency for physicians to focus on the system in which they have developed particular expertise is important. Teams with a high proportion of therapists and medical staff willing and able to address symptoms related to multiple systems will be essential. The ‘guiding hand’ that is often absent when patients attend multiple clinics separately to discuss uncoordinated management plans will need to be both visible and effective. An additional skillset will include familiarity with ‘functional’ or medically unexplained symptoms. Although Ayoubkhani et al’s study showed a high prevalence of new post-covid diagnoses (e.g. diabetes, kidney disease, cardiovascular events), early experience does suggest that symptoms may be disproportionate to observable organ dysfunction in up to 30% of patients [1] [2]. A large Chinese study found that the main symptoms were fatigue, muscle weakness, sleep difficulties, and anxiety/depression [3]. Few system-based specialists are equipped to help with these. Although there is increasing evidence that subtle chemical and biological changes do underpin many functional conditions, physicians are often quick to discharge patients from the clinic back to primary care with advice once one has been diagnosed [4][5]. This will not suffice for patients with post-covid-19 syndrome.
Beyond clinical skills, the existing economic model may need to be altered. Currently, secondary care clinics look for ways to reduce their new-to-follow up ratios by discharging patients after one or two visits. There are significant financial incentives for such ‘quick turnarounds’, as payment to providers is not proportionate to the number of attendances or investigations. This arrangement comes under a ‘payment by results’ (PBR) model, but this is not the same as ‘payment by outcomes’. The financial transaction is not related to ultimate cure or improvement. In this new and challenging area of medicine where achievable clinical outcomes are still poorly understood, subjective improvement in symptom burden should to be a key marker of successful management. Formal use of patient reported outcome measures (PROMs) remains poorly developed in primary and secondary care, despite their collection by providers since 2009 [6]. If there was ever a condition where their use should be prioritised, and traditional economic models challenged, it is post-covid-19.
1. Ayoubkhani D, Khunti K, Nafilyan V, Maddox T, Humberstone B, Diamond I, Banerjee A. Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ. 2021 Mar 31;372:n693
2. Dennis A, Wamil M, Alberts J, Oben J, Cuthbertson DJ, Wootton D, Crooks M, Gabbay M, Brady M, Hishmeh L, Attree E, Heightman M, Banerjee R, Banerjee A; COVERSCAN study investigators. Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: a prospective, community-based study. BMJ Open. 2021 Mar 30;11(3):e048391.
3. Huang C, Huang L, Wang Y, Li X, Ren L, Gu X, Kang L, Guo L, Liu M, Zhou X, Luo J, Huang Z, Tu S, Zhao Y, Chen L, Xu D, Li Y, Li C, Peng L, Li Y, Xie W, Cui D, Shang L, Fan G, Xu J, Wang G, Wang Y, Zhong J, Wang C, Wang J, Zhang D, Cao B. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021 Jan 16;397(10270):220-232.
4. Bransfield RC, Friedman KJ. Differentiating Psychosomatic, Somatopsychic, Multisystem Illnesses, and Medical Uncertainty. Healthcare (Basel). 2019 Oct 8;7(4):114.
5. Ng QX, Soh AYS, Loke W, Lim DY, Yeo WS. The role of inflammation in irritable bowel syndrome (IBS). J Inflamm Res. 2018 Sep 21;11:345-349.
6. Timmins N. NHS goes to the PROMS. BMJ. 2008 Jun 28;336(7659):1464-5.
Competing interests: No competing interests