1
|
O’Hare AM, Vig EK, Iwashyna TJ, Fox A, Taylor JS, Viglianti EM, Butler CR, Vranas KC, Helfand M, Tuepker A, Nugent SM, Winchell KA, Laundry RJ, Bowling CB, Hynes DM, Maciejewski ML, Bohnert ASB, Locke ER, Boyko EJ, Ioannou GN. Complexity and Challenges of the Clinical Diagnosis and Management of Long COVID. JAMA Netw Open 2022; 5:e2240332. [PMID: 36326761 PMCID: PMC9634500 DOI: 10.1001/jamanetworkopen.2022.40332] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
IMPORTANCE There is increasing recognition of the long-term health effects of SARS-CoV-2 infection (sometimes called long COVID). However, little is yet known about the clinical diagnosis and management of long COVID within health systems. OBJECTIVE To describe dominant themes pertaining to the clinical diagnosis and management of long COVID in the electronic health records (EHRs) of patients with a diagnostic code for this condition (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code U09.9). DESIGN, SETTING, AND PARTICIPANTS This qualitative analysis used data from EHRs of a national random sample of 200 patients receiving care in the Department of Veterans Affairs (VA) with documentation of a positive result on a polymerase chain reaction (PCR) test for SARS-CoV-2 between February 27, 2020, and December 31, 2021, and an ICD-10 diagnostic code for long COVID between October 1, 2021, when the code was implemented, and March 1, 2022. Data were analyzed from February 5 to May 31, 2022. MAIN OUTCOMES AND MEASURES A text word search and qualitative analysis of patients' VA-wide EHRs was performed to identify dominant themes pertaining to the clinical diagnosis and management of long COVID. RESULTS In this qualitative analysis of documentation in the VA-wide EHR, the mean (SD) age of the 200 sampled patients at the time of their first positive PCR test result for SARS-CoV-2 in VA records was 60 (14.5) years. The sample included 173 (86.5%) men; 45 individuals (22.5%) were identified as Black and 136 individuals (68.0%) were identified as White. In qualitative analysis of documentation pertaining to long COVID in patients' EHRs 2 dominant themes were identified: (1) clinical uncertainty, in that it was often unclear whether particular symptoms could be attributed to long COVID, given the medical complexity and functional limitations of many patients and absence of specific markers for this condition, which could lead to ongoing monitoring, diagnostic testing, and specialist referral; and (2) care fragmentation, describing how post-COVID-19 care processes were often siloed from and poorly coordinated with other aspects of care and could be burdensome to patients. CONCLUSIONS AND RELEVANCE This qualitative study of documentation in the VA EHR highlights the complexity of diagnosing long COVID in clinical settings and the challenges of caring for patients who have or are suspected of having this condition.
Collapse
Affiliation(s)
- Ann M. O’Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Elizabeth K. Vig
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Theodore J. Iwashyna
- Pulmonary and Critical Care Medicine, Department of Health Policy & Management, School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | | | - Elizabeth M. Viglianti
- Department of Internal Medicine Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
| | - Catherine R. Butler
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Mark Helfand
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Anaïs Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Shannon M. Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Kara A. Winchell
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Ryan J. Laundry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - C. Barrett Bowling
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
- College of Public Health and Human Sciences and Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Emily R. Locke
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - Edward J. Boyko
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - George N. Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| |
Collapse
|
2
|
Gean EG, Ayers CK, Winchell KA, Freeman M, Press AM, Paynter R, Kansagara D, Nugent SM. Biological measures and diagnostic tools for Gulf War Illness - A systematic review. Life Sci 2021; 275:119360. [PMID: 33741418 DOI: 10.1016/j.lfs.2021.119360] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/22/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
AIMS Gulf War Illness (GWI) is a chronic multisymptom illness with debated etiology and pathophysiology. This systematic review catalogues studies of validated biological tests for diagnosing GWI and of associations between biological measures and GWI for their promise as biomarkers. MAIN METHODS We searched multiple sources through February 2020 for studies of diagnostic tests of GWI and of associations between biological measures and GWI. We abstracted data on study design, demographics, and outcomes. We assessed the risk of bias of included studies. KEY FINDINGS We did not identify any studies validating tests of biomarkers that distinguish cases of GWI from non-cases. We included the best-fitting studies, 32 completed and 24 ongoing or unpublished studies, of associations between GWI and biological measures. The less well-fitting studies (n = 77) were included in a Supplementary Table. Most studies were of the central nervous and immune systems and indicated a significant association of the biological measure with GWI case status. Biological measures were heterogeneous across studies. SIGNIFICANCE Our review indicates that there are no existing validated biological tests to determine GWI case status. Many studies have assessed the potential association between a variety of biological measures and GWI, the majority of which pertain to the immune and central nervous systems. More importantly, while most studies indicated a significant association between biological measures and GWI case status, the biological measures across studies were extremely heterogeneous. Due to the heterogeneity, the focus of the review is to map out what has been examined, rather than synthesize information.
Collapse
Affiliation(s)
- Emily G Gean
- Scientific Resource Center for the Agency for Healthcare Research and Quality Evidence-based Practice Center, Portland VA Research Foundation, United States of America.
| | - Chelsea K Ayers
- VA Portland Health Care System Evidence Synthesis Program, United States of America
| | - Kara A Winchell
- VA Portland Health Care System Evidence Synthesis Program, United States of America
| | - Michele Freeman
- VA Portland Health Care System Evidence Synthesis Program, United States of America
| | - Ashlyn M Press
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Robin Paynter
- VA Portland Health Care System Evidence Synthesis Program, United States of America
| | - Devan Kansagara
- VA Portland Health Care System Evidence Synthesis Program, United States of America
| | - Shannon M Nugent
- VA Portland Health Care System Evidence Synthesis Program, United States of America
| |
Collapse
|
3
|
Nugent SM, Freeman M, Ayers CK, Winchell KA, Press AM, O’Neil ME, Paynter R, Kansagara D. A Systematic Review of Therapeutic Interventions and Management Strategies for Gulf War Illness. Mil Med 2021; 186:e169-e178. [PMID: 33128563 DOI: 10.1093/milmed/usaa260] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/28/2020] [Accepted: 10/26/2020] [Indexed: 12/26/2022] Open
Abstract
ABSTRACT
Introduction
After the 1990 to 1991 conflict in the Persian Gulf, many Gulf War Veterans began reporting numerous unexplained symptoms including, but not limited to, systemic pain, fatigue, flu-like symptoms, and difficulty with memory/concentration. These symptom clusters are now referred to as Gulf War Illness (GWI). Although the etiology of GWI is still debated, as many as 250,000 former service members have been continually suffering from GWI since 1991, making the need for treatment urgent. A broad variety of treatments have been considered for GWI, but there has not been a broad and comprehensive assessment of what is known and not known about GWI treatment. We conducted a systematic review to catalogue the types of treatments that have been examined for GWI, to evaluate the effectiveness and harms of these interventions, and to identify promising and ongoing areas of future GWI treatment research.
Materials and Methods
We searched electronic databases, trial registries, and reference lists through September 2019 for randomized controlled trial and nonrandomized controlled trial and cohort studies directly comparing interventions for Veterans with GWI to each other, placebo, or usual care. We abstracted data on study design, demographics, interventions, and outcomes. Two reviewers independently assessed studies for inclusion, quality, and strength of evidence (SOE) using prespecified criteria. We resolved discordant ratings by discussion and consensus.
Results
We identified 12 randomized controlled trials, each of which examined a different intervention for GWI. We found moderate SOE that cognitive behavioral therapy and exercise, separately and in combination, were associated with improvements in several GWI symptom domains. There was low SOE of benefit from two mindfulness-based interventions and continuous positive airway pressure (CPAP). Mindfulness-based stress reduction improved pain, cognitive functioning, fatigue, depression, and posttraumatic stress disorder (PTSD), whereas mind-body bridging improved fatigue, depression, posttraumatic stress disorder, and sleep, although pain and other outcomes did not improve. Continuous positive airway pressure improved overall physical health, pain, cognitive functioning, fatigue, mental health, and sleep quality in a small study of Veterans with sleep-disordered breathing and GWI. We found moderate SOE that doxycycline is ineffective for GWI in mycoplasma DNA-positive Veterans and increases the risk of adverse events compared with placebo. We also found 33 ongoing, single-arm pilot, or unpublished studies examining a variety of interventions.
Conclusion
Cognitive behavioral therapy (moderate SOE), exercise (moderate SOE), and mindfulness-based interventions (low SOE) may be effective in improving several symptom domains in patients with GWI. Doxycycline was ineffective and associated with harms (moderate SOE). Larger, more rigorous studies are needed to confirm the benefits found in completed trials. A wide array of treatments are being assessed in ongoing trials. A sufficient evidence base will need to be developed to guide clinicians about which treatments are most likely to be effective in clinical practice and which treatments should be avoided.
Collapse
Affiliation(s)
- Shannon M Nugent
- Nugent and O’Neil are Dept of Psychiatry; Kansagara is Dept of Medicine, VA Portland Health Care System Evidence Synthesis Program, Portland, OR 97239, USA
- Oregon Health and Science University, Portland, OR 97239, USA
| | - Michele Freeman
- Nugent and O’Neil are Dept of Psychiatry; Kansagara is Dept of Medicine, VA Portland Health Care System Evidence Synthesis Program, Portland, OR 97239, USA
| | - Chelsea K Ayers
- Nugent and O’Neil are Dept of Psychiatry; Kansagara is Dept of Medicine, VA Portland Health Care System Evidence Synthesis Program, Portland, OR 97239, USA
| | - Kara A Winchell
- Nugent and O’Neil are Dept of Psychiatry; Kansagara is Dept of Medicine, VA Portland Health Care System Evidence Synthesis Program, Portland, OR 97239, USA
| | - Ashlyn M Press
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, NC 27705, USA
| | - Maya E O’Neil
- Nugent and O’Neil are Dept of Psychiatry; Kansagara is Dept of Medicine, VA Portland Health Care System Evidence Synthesis Program, Portland, OR 97239, USA
- Oregon Health and Science University, Portland, OR 97239, USA
| | - Robin Paynter
- Nugent and O’Neil are Dept of Psychiatry; Kansagara is Dept of Medicine, VA Portland Health Care System Evidence Synthesis Program, Portland, OR 97239, USA
| | - Devan Kansagara
- Nugent and O’Neil are Dept of Psychiatry; Kansagara is Dept of Medicine, VA Portland Health Care System Evidence Synthesis Program, Portland, OR 97239, USA
- Oregon Health and Science University, Portland, OR 97239, USA
| |
Collapse
|