Pilot may determine viability of long COVID management models

Ken McCroary

13/03/2023 9:31:42 AM

Dr Ken McCroary on the results of tracking post-COVID sequalae in south-west Sydney, and what is needed for long-term viability of a GP-led clinic.

A female doctor speaking with a patient.
The majority of participants in the pilot study reported their ‘healthcare needs were met’ by the team-based model of care, which included practice nurses working with GPs.

One of the recurring themes of the ongoing COVID-19 pandemic has been confusion and uncertainty. Decision making with a lack of data has been a necessary but challenging component of dealing with the pandemic, both in primary care and throughout the wider community.
This was highlighted to me once again following my appearance before the House of Representatives Standing Committee on Health, Aged Care and Sport’s Inquiry into long COVID and repeated COVID infections
It was obvious that the members of the committee were very keen to hear about experiences, particularly in our region of outer-metropolitan south-west Sydney with our high infection rates, high mortality, and significant social struggles with living under curfew and the other restrictions the rest of society faced. 
Unfortunately, there is a deficit of objective data about the infection and subsequent long COVID issue for decision makers to rely upon to make successful long-term plans and recommendations.
While my appearance before the committee was mainly as an advocate for the funding for GP-led multidisciplinary primary care management of post-COVID sequalae, I came away with the request to obtain some objective local data regarding post-viral COVID sequalae.
I have since been working as the GP lead on the South Western Sydney COVID-19 Working Group throughout the pandemic, including with the South Western Sydney PHN COVID Monitoring Project.
The project’s pilot was a PHN-commissioned model to support practice nurses in primary care to provide telehealth monitoring for COVID-positive patients across south-west Sydney. Local government areas included Bankstown, Camden, Campbelltown, Fairfield, Liverpool, Wollondilly and Wingecarribee. 
The project subsequently morphed into also including follow up of participants longer term in a patient-reported measures trial relating to long COVID, using the Agency for Clinical Innovation’s HOPE platform. Five keystone practices were initially enrolled for a six-month program, but with post-COVID sequalae issues developing, the program was extended for another six months with four of the practices remaining.
The five practices managed and supported just over 400 patients in total, which included the practice nurse regularly contacting them via telehealth and urgent escalation to the practice GPs when required, following initial GP assessment for diagnosis management and suitability for antiviral therapies such as sotrovimab, and later the oral antivirals nirmatrelvir/ritonavir and molnupiravir.
In my opinion, the project was successful due to the fact that the practice nurse was funded to participate in patient management independent of GP presence, which is remarkably different to our normal practice where primary health nurses are not funded to perform any activities without our presence. This freed up the time for GPs to continue their day-to-day practice, as 87% of all the assessments in the program were made independently by the practice nurse.
What was most interesting was the longer-term follow-ups using a post-COVID functional survey and the C19-YRS tool.
The C19-YRS screens for the most common symptoms of long COVID. It grades severity of symptoms to provide a summative score of burden out of 100 and grades the functional impact of the condition on daily activities out of 50. Both of these are used to calculate a ‘symptoms now’ and a ‘functional now’ score, as well as ‘pre-COVID symptoms and function’ scores based on the answers regarding their symptoms pre-COVID. An ‘overall now’ health score out of 10 – with zero being the worst and 10 being the best – is also provided. 
Post-COVID symptoms of weakness and sleep problems were the most prevalent, with the highest occurrence scores over zero. Other long-term post-COVID sequalae issues included skin rashes, palpitations, fevers and dizziness.
Just over 18% of participants’ post-COVID functional assessments had symptoms of post-COVID sequalae in this pilot study.
The incidences of post-COVID or long-COVID symptoms worldwide have been reported quite variably from 3% to 85%, depending on patient cohorts and other risks such as pre-morbid conditions, vaccination status, infection severity and ICU admission.
I was initially surprised to see that the percentage of post-COVID symptoms in the south-west Sydney region looked to be about double the numbers we were expecting from other reports suggesting 10% as a common number of patients. 
On reflection, the region in outer-metropolitan Sydney has a significantly high incidence of lower socioeconomic health-related pre-morbid issues with the other social determinates of health such as employment, Aboriginal and Torres Strait Islander origin, refugee status, and culturally and linguistically diverse background – particularly our Pacific Islander population with their mortality of COVID during the pandemic being 12 years younger than the rest of the Australian population average. 
Conclusions and long-term viability
There were some interesting conclusions from the study participants’ post-experience survey responses:

  • With a mind towards new blended funding payments for general practice, when asked ‘Did you feel your healthcare needs were met by this service?’, 97.6% answered yes.
  • When asked ‘In the absence of this service what would you have accessed to address your health needs?’, 14.3% of the patients interviewed stated that they would attend the emergency department.
  • When asked ‘Has this service helped you better understand your COVID diagnosis?’, 95.2% of patients answered yes. 
  • When asked about recommendations and feedback, several respondents mentioned that they would recommend keeping the program which positively reflects the benefits of properly funded general practice-led primary care.
The data from our pilot study has been forwarded to the House of Representatives Committee’s Inquiry into long COVID and repeated COVID infections to highlight the significant numbers of potential individuals with long-term sequalae, and the inevitability that this would be a general practice-led management space that requires significant new and ongoing funding for primary healthcare in Australia.
We believe this would be a suitable model for managing post and long COVID, with our clinic requiring funding to support practice nurses and allied health practitioners working with GPs.
The raw data from the pilot program and our outlined advocacy for appropriately funded GP-led care can both be accessed via the GPLink website.
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GP-led clinics long COVID pilot study post-COVID sequalae south-west Sydney

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