The long-term effects of COVID-19 on health and wellbeing are unclear, and in the coming months the focus of the disease will shift from managing the outbreak to recovery, rehabilitation and optimising wellbeing of those directly or indirectly affected by COVID-19. Early research suggest its impact is both physical and psychological, and prescribers caring for people in the community will be at the forefront of supporting recovery. In this third and final roundup focusing on COVID-19, research on the long-term effects of the disease (British Thoracic Society (BTS), 2020a, 2020b) and psychological effect of lockdown will be presented (Ahmed et al, 2020). The outbreak has forced a rapid shift from face-to-face to remote consultations and the final part of this roundup will explore recent evidence relating to telehealth and e-consultation (Kruse et al, 2017; Orlando et al, 2019; Vimalananda et al, 2020).
Respiratory follow-up for people with a radiological diagnosis of COVID-19
This article provides follow-up guidance on patients with the most severe COVID-19 disease, namely, those that required critical care or had changes noted on chest x-ray consistent with COVID-19 pneumonia. Drawing on data from SARS-CoV and Middle Eastern coronavirus (MERS-CoV) outbreaks, where in 20–60% of cases patients experienced long-term symptoms similar to pulmonary fibrosis, it suggests that COVID-19 may experience similar physiological, life limiting complications. Pulmonary fibrosis is a condition that is often described as ‘scarring’ of the lungs and shortness of breath, fatigue, reduced exercise tolerance and dry cough are common symptoms. The guidance recommends that, following discharge from hospital, a holistic follow-up plan for people is recommended. As a result of social distancing measures, the guidance recommends that the majority of follow-ups should be arranged remotely, with a 12 week face-to-face follow-up reserved for those with the most severe post-COVID-19 complications. Follow-ups should include symptom control, assessment and management of breathlessness, psychological support, including management of anxiety, and appropriate rehabilitation (BTS, 2020a). The report also suggests that people who have had COVID-19 may also have a higher prevalence of thromboembolic disease (BTS, 2020b). Prescribers should be aware of the higher incidence of thromboembolic disease in this group and if symptoms are evident, local assessment and treatment algorithms followed.
Pyschological distress in people in lockdown during COVID-19 pandemic
This study took place in Hubei Province, China and its aim was to assess the mental health of people during the COVID-19 pandemic. Using four validated instruments to measure anxiety, depression, alcohol use and mental wellbeing, 1074 participated in an online survey. Recruitment was via a social media site in China, and the age range of participants was 14–68 years, with a median age of 33.5 years. Findings suggested that, compared to pre-COVID-19 surveys, mental wellbeing was reportedly lower, and alcohol use, anxiety and depression higher. This was particularly notable in people between 21 and 40 years old. In the context of lockdown, the findings may not be surprising, but the results should be interpreted with caution for the following reasons:
- The study may not be representative of the general population, because 50% of survey respondents were from the epicentre of the outbreak, Wuhan province, where lockdown restrictions may have been stricter. This may have resulted in higher levels of anxiety and depression, higher alcohol intake and lower levels of wellness than the general population
- Recruitment was via social media, which may attract recruitment from a younger population, and may not necessarily reflect the views of the older residents in China
- It was unclear how they verified the authenticity of those completing, personal information may not be correct and it was unclear how they ensured one person completed one, rather than multiple, surveys.
That said, it has provided a preliminary insight into how health and wellbeing may be affected as a consequence of lockdown. Next steps may be a more robust study globally, exploring the psychological impact of the pandemic, allowing evidence-based, appropriate psychological rehabilitation to be implemented after COVID-19. This could allow clinicians and prescribing practitioners working in psychological services to target resources to those most affected, thus reducing risk and improving quality of life.
‘Findings suggested that, compared to pre-COVID-19 surveys, mental wellbeing was reportedly lower, and alcohol use, anxiety and depression higher’
Consultation: towards a new perspective
Since lockdown, professional bodies have published recommendations for safe remote consultation and online prescribing (British Medical Association, 2020; Royal College of Nursing, 2020; Chartered Society for Physiotherapy, 2020; Royal Pharmaceutical Society, 2020). Remote consultation, or telehealth, is established in remote and rural areas and research exploring patients’ perceptions of the approach and its impact on patient, carer and clinical outcomes is evident. For example, a systematic review and narrative analysis of 44 articles investigated the association between telehealth and patient satisfaction (Kruse et al, 2017). Results suggested that it may improve patient outcomes, was easy to use and improved communication. The review also reported that it was relatively cost effective, reducing travel time and allowing for more efficient access to expert health professional advice. A second, more recent review looked at a wider range of literature and investigated telehealth from the perspective of patient and caregiver (Orlando et al, 2019). The search yielded 36 eligible studies and the main findings reported were consistent with findings from Kruse et al (2017), that patients and caregivers were satisfied with telehealth.
However, a recent systematic review suggested there is limited evidence on its effect on clinical outcomes. Vimlananda et al (2020) investigated e-consultation across four main outcomes; overall health, cost, patient and clinician experience. The 63 articles eligible for review were conducted across a variety of areas including cardiology, emergency care and renal medicine and reported positive results. However, all were observational in design and considered to be modest quality evidence. The authors recommend that future research may adopt alternative approaches, such as quasi-experimental, before and after, or implementation science methodologies and longer follow-up. They argue this would provide a broader and more robust evaluation of e-consultation, which is vital when moving from face-to-face to online consultation. This need for good quality evidence evaluating e-consultation may be an opportunity for nurse, pharmacist and allied health prescribers to collaborate with the academic community to design a high-quality mixed methods study investigating e-consultation and its impact on clinical and medicines-related outcomes.
Conclusion
COVID-19 has restricted everyday life, and for some, will have a lasting effect on their health and wellbeing. As prescribing practitioners working in healthcare, we have had to rapidly shift to new ways of working and consider how to effectively support patients without compromising patient experience or quality of care.
Whilst telehealth cannot replace face-to-face consultations and there are obvious limitations relating to physical assessment and care intervention, there is some evidence to support its use. Albeit of variable quality, research suggests that clinicians, caregivers and patients find it is a satisfactory alternative, but further high-quality research is warranted. In the meantime, necessity is driving the change to e-consultation and will reduce the spread of COVID-19. It provides equal access to healthcare, which is of particular importance to the most vulnerable in society.