GPs and hospitals to tackle ‘long COVID’ together

Doug Hendrie

14/09/2020 4:22:45 PM

A new clinical pathway linking GPs, hospitals and coronavirus survivors is set to launch as an expert calls for focus on the long tail of the virus.

Exercising man out of breath
Difficulty undertaking exercise has been a common issue following ‘mild’ cases of COVID-19.

Pathway creators say the new approach will bring together GPs and hospital physicians to tackle the longer-term impacts of the pandemic, while prominent clinicians have praised the rapid response to an emerging clinical issue. 
The new pathway is set to launch this week and will cover patients attending many of the hospitals covering second-wave COVID hotspots in Melbourne’s northern and western suburbs, including Royal Melbourne, Western Health and Werribee Mercy, as well as linking to an existing hospital in the in-home program run by Djerriwarrh Health Services.

Two-thirds of Melbourne’s active COVID-19 cases live in this region as of 12 September, according to figures from the North Western Melbourne Primary Health Network (NWM PHN). 
The pathway – to be published on the Healthpathways site – will provide guidance and referral pathways for clinicians treating Victoria’s almost 18,000 COVID survivors as they grapple with potential longer-term health issues. 
The move comes as leading epidemiologist and World Health Organization (WHO) advisor Professor Mary-Louise McLaws called for greater attention to treatments and rehabilitation for ‘long COVID’ patients, flagging it as a major emerging issue in the global fight against the virus. 
She told newsGP ‘mild’ cases of the virus should be renamed ‘non-hospitalised’ cases, given the longer-term damage to heart, lungs and brain seen in a minority of survivors, as well as the more common issues such as fatigue, breathlessness, brain fog, difficulty undertaking exercise, and even psychological symptoms resembling PTSD in those who were in intensive care.
‘It’s very hard to know how to go about preventing long COVID. It’s really very disconcerting,’ Professor McLaws said.
‘We need to focus on this if we are trying to protect the young and ensure they have a good middle age.’  
The best estimates available suggest long COVID symptoms occur in 10–35% of patients overall, according to research in the British Medical Journal and the Morbidity and Mortality Weekly Report published by the US Centers for Disease Control and Prevention.
While there is limited evidence on symptoms and treatments specifically for long COVID, clinicians have drawn on the experience of survivors of the closely related SARS-CoV-1 coronavirus which also triggered post-viral fatigue and other issues.
The new pathway has been created by GP Dr Kate Graham, from the Western Victoria PHN, aided by Dr Scott Parsons from NWM PHN and with input from Melbourne Health. The pathway is intended to apply state-wide, and will tap into the GP-focused COVID care program run by community health organisation cohealth.

cohealth GP and medical epidemiologist Dr Nicole Allard told newsGP there is an increasing need for pathways of care for people with persistent post-COVID symptoms.  
‘We are really aware there is a need for referral pathways for GPs, and for clear directions about symptomatology if it is persisting,’ she said.
‘There is very little evidence in this area, so a lot of recommendations are taken from other diseases.’
Respiratory physician Dr Alastair Miller is clinical lead for the Royal Melbourne Hospital’s virtual hospital, which helps provide care for milder COVID patients in the community.
He told newsGP the new pathway will bring GPs and hospital clinicians together in collaborative forms of care.
‘Everyone is pushing for more collaboration between primary and secondary care and this is a great chance for us to do that,’ Dr Miller said. ‘This will be a very interprofessional space.
‘GPs are well placed to provide psychological support and to refer off for formal support if necessary.
‘The role hospitals can play is to exclude severe physiological issues such as heart disease, lung disease and neurological disease. But a lot of the ongoing management will be by GPs in the community.’
Dr Miller said that the pathway had to be drawn largely from other similar disease.
‘We based this pathway on the first SARS, which also had [post-viral] breathlessness, fatigue and psychological distress,’ he said.
‘This pathway will provide a baseline for GP assessment, both for people in the hospital and those with milder disease. The key is really going to be doing a baseline assessment with a clinical review and investigations as appropriate and to refer early if concerned.
‘We and everyone else are scrambling to get a service that is responsive.’  

Infectious diseases clinician Associate Professor Steven Tong said post-COVID patients are emerging as an important group.

Dr Miller said the most frequent symptom is fatigue, followed by breathlessness.
‘What we have found is that symptoms are often out of proportion to physiological abnormalities,’ he said.
‘For instance, people are not hypoxic, but remain incredibly breathless. We’re seeing young, fit people who are very breathless despite having lung function.’
Royal Melbourne Hospital infectious diseases clinician Associate Professor Steven Tong told newsGP post-COVID patients are emerging as an important group.
‘At the moment, it’s a data-free zone as to whether interventions make any difference to long-term outcomes. No one can say,’ he said.
‘It’s going to be hard to work out what interventions made a difference. We just don’t know at this stage.’   
Melbourne respiratory physician Associate Professor Louis Irving told newsGP the new pathway for post-COVID care is ‘exactly what needed to be done’ to tackle the emerging issue.   
‘It’s terrific the PHNs are going to provide a GP-centric holistic model to assess these patients as individuals,’ he said.
Post-COVID symptoms cover a wide spectrum, Associate Professor Irving said.
He recently treated patients with severe fatigue, sleep and mood disturbances and heart palpitations, a combination suggesting both PTSD and chronic fatigue. Such patients represent the extreme end of the spectrum, he said, having often come out of intensive care with lung scarring and/or cardiac abnormalities as well as deconditioning.
But many have milder symptoms.  
‘Some seem to simply not have fully recovered from a virus, with their main problem being a lack of energy. They just don’t have as much petrol in the tank,’ Associate Professor Irving said.
‘For these patients, we can reassure them they don’t have lung scarring or cardiomyopathy or a neurological syndrome, and to suggest it is likely that time will heal them.’
Professor McLaws said that while treatments like dexamethasone and remdesivir have helped address severe cases of the disease, there are no proven treatments available to address the debilitation of long COVID.
‘A lot of people will tell you it wasn’t mild and that the effects are unpredictable, going from depression and fatigue to very serious ones like breathing difficulties and heart conditions. We haven’t seen any improvements for that group of patients,’ she said.
‘Young people aged 20–39 now represent 40% of cases in Australia. That’s a very large group. We don’t want them going into middle age with chronic ill health.
‘We don’t know how long COVID lasts for, or whether it impacts productivity or even fertility. That’s why it’s so important to focus on how to treat non-hospitalised COVID, as well.
‘At the moment, clinical epidemiologists are focusing on the more serious levels. I predict they will start to focus on the majority of cases now that long COVID is accepted as an adverse event.’
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