Long COVID – integrated approaches to chronic disease management?

The global burden of chronic disease is soaring, increasing pressure on healthcare services. In the United States of America alone, it is estimated that chronic disease accounts for 86% of total annual healthcare costs, and similar figures have been demonstrated across Europe. Whilst historically positioned to address acute illnesses, there is growing pressure for healthcare systems to manage areas of chronic disease. There is no doubt that the prevalence of chronic disease and the pressure that brings have increased in recent decades and are on a frightening upwards trajectory. This has in part been impacted by increased public awareness, advances in medicine, an ageing population and a reduction in adopting healthy living behaviours. Collectively, this represents a huge challenge for global healthcare systems, which have experienced widespread funding and resource cuts and with little or no investment in people. In recent times, healthcare systems in globally have been stretched beyond any imaginable limits by the coronavirus (COVID-19) pandemic.

The development of effective vaccines and increased knowledge relating to treatments have significantly reduced the severity of acute infections. Despite these interventions, reports highlight that one in ten people following a COVID-19 infection will demonstrate persistent, episodic, and often disabling symptom profiles known colloquially as post-COVID syndrome or Long COVID. This broad multi-system, complex condition which occurs in the weeks and months following a probable or confirmed infection with SARs-COV-2, that affects around ∼150 million people worldwide. Like many chronic conditions, the aetiology of Long COVID is heterogeneous and represents a set of dynamic and interacting factors that intersect to produce a complex clinical presentation which broadly affects functional status and quality of life. In the context of Long COVID, assessment services have been established to support patients which are underpinned by multi-disciplinary and joined up care approaches to address and where possible restore functional status. Whilst termed multi-disciplinary, it is arguable that these approaches are more reflective of interdisciplinary practice, where a subtle but clear distinction in approach can be made (Figure). From our observations, the more complex Long COVID cases are commonly discussed collectively by the relevant specialists, that engage in cross disciplinary conversations to develop complex treatment pathways to improve clinical and patient outcomes. Despite this well practiced approach, previous data that reviews its effectiveness remains equivocal in the context of service utilisation, long-term patient outcomes and patient experience. Lived experience data from Long COVID patients highlight a range of clinical experiences that includes excessive waiting times, lack of follow up and investigation, being passed between clinical specialities and in some extreme cases being dismissed from services and medical gaslighting. To prevent an overly and somewhat unfair critical appraisal of the established services and those running them, it must be highlighted that these services are embryonic and have been developed in the absence of clinical and pathophysiological and prognostic research that will continue evolve and refine service provision. It is also prudent to recognise the diverse complexity of Long COVID symptomology and a lack of effective treatment and management strategies that undoubtedly impacts service provision and patient experiences. What the lived experience data highlights is highly varied and reveals disparate approaches to reviewing and managing Long COVID cases (i.e., there is little consistency, or a standardised model informing Long COVID services).

This creates an important and timely opportunity to review the approaches taken to support Long COVID patients and more broadly the approach to managing and treating chronic disease. Utilising previous approaches there is a need to develop and implement a substantive pathways that are underpinned with whole system thinking approaches, and enriched with interdisciplinary consideration and practice. In the context of Long COVID it feels appropriate to convene the relevant specialists to discuss the mechanistic and integrated issues that affect Long COVID patients. Again, acknowledge the broad challenges of Long COVID, it might be prudent to develop assessment services that incorporate objective triaging and monitoring to establish each patient's presentation and increase the understanding between the dynamic and the interrelating cause-effect factors that underpin Long COVID. This information obtained over time (i.e., whilst waiting for an appointment) can be used to direct patients towards the most important appropriate support services. Adopting such approaches will undoubtedly improve patient outcomes and experiences but it represents a step change in thinking that will cause logistical challenges as all parties will need to listen, learn, and collaborate with each other and seek a mutual understanding and approach. Moving towards a coordinated and integrated approach could lead to the design and implementation of efficient and effective services that can address a growing and significant burden to healthcare services which could be considered for adoption more broadly long-term conditions.

Long COVID is an unprecedented burden to healthcare systems and patients worldwide, and the long-term impacts for patients and healthcare providers are still to be realised. The authors acknowledge that the development of Long COVID services is still very much embryonic, however, services are required at pace and scale to support the >2 million people in the UK and >150 million globally living with persistent and debilitating symptom profiles.