Long-term Effects of COVID-19 Pose Challenges for Patients, Providers, and Payers

Issues like fatigue, muscle pain, and brain fog affect some COVID-19 survivors for lengthy periods. Experts suggest there is a growing need to better understand and respond to this phenomenon.

While many people get better within several weeks after contracting COVID-19 others do not experience a quick or straightforward recovery. For some, symptoms last for many weeks or months, which is commonly referred to as “Long COVID.” For others, new health issues pop up following acute infection, whether symptoms appeared initially or not. Together, these effects are called postacute sequelae of SARS-CoV-2 infection, or PASC for short.

Post-COVID conditions include a wide array of “new, returning, or ongoing health problems” experienced 4 weeks or more after being infected with the virus that causes COVID-19, according to a Centers for Diseases Control and Prevention (CDC) overview. While these conditions seem to be less common in children and adolescents, these younger age groups can also be affected.

And there is no one size fits all. People have experienced differing combinations of symptoms, including fever, dizziness, shortness of breath, fatigue, cough, headache, problems thinking or concentrating, joint or muscle pain, rash, heart palpitations, sleep issues, anxiety, and depression, among others. For some, the health issues are severe enough to interfere with everyday activities like breathing, thinking, working, or exercising.

While the medical community is aware that some patients develop prolonged symptoms and difficulty with everyday tasks, there is still plenty that remains a mystery. The fuller extent of the impact is not yet known at least in part because many of these symptoms are not readily detectable.

“The most important challenge we face is our inability to pinpoint specific physiological issues in lab work, imaging, and physical examinations that correlate to patients’ reported symptoms,” Eyal Leshem, MD, director of the Center for Travel Medicine and Tropical Diseases at Sheba Medical Center and clinical associate professor at Tel Aviv University School of Medicine told First Report Managed Care.

Another critical issue is the lack of an effective treatment for these patients. “We do not currently know of a specific intervention, such as a drug, that would be effective in averting this condition,” added Dr Leshem, who is also a guest researcher at the CDC and consultant to the World Health Organization.

“The implications for so many people are so great,” Walter Koroshetz, MD, director of the National Institute of Neurological Disorders and Stroke at the National Institutes of Health (NIH), said during a webinar focused on Long COVID hosted by the National Institute for Health Care Management (NIHCM) Foundation on November 17, 2021. “We’re unfortunately dealing from a position of a real lack of knowledge.”

It has not been a big surprise that those heading into intensive care units ICUs and developing acute respiratory distress syndrome from viral pneumonia would have a lengthy recovery period and a need for special care. The big surprise, Dr Koroshetz explained, is that COVID-19 can affect so many different organ systems and that even those with mild disease—and no need for hospitalization or an ICU stay—can have persistent symptoms.

There is a need to learn how to best care for people facing these long-term health issues, but one of the challenges is a lack of data to help inform those considerations. The United Kingdom’s National Institute for Health and Care Excellence has put out guidelines, Dr Koroshetz noted, that are essentially “symptomatic management.” In other words, they involve identifying a patient’s issues and trying to attack those as effectively as possible.

Meanwhile, NIH has launched a program to understand the underlying biology of people recovering from SARS-CoV-2 infection and to determine what is different about those who make a good recovery compared with those who suffer from symptoms several months later. The initiative is called RECOVER (Researching COVID to Enhance Recovery) and is building a nationwide study population to support research centered on the long-term effects of COVID-19.

According to the RECOVER program’s website (www.recovercovid.org), RECOVER seeks to “understand, prevent, and treat” PASC, including Long COVID. The initiative aims to involve tens of thousands of people, including a diverse group of participants reflecting the population of the United States, so that findings can be applied broadly. Several groups and organizations are collaborating through the RECOVER Consortium to launch studies, which are expected to include adults, children, pregnant women, tissue pathology (autopsy), and real-world data.

Collectively, the research will explore an array of questions. What does recovery from SARS-CoV-2 infection look like among different groups of people? How many people continue to experience symptoms after acute infection, and how many develop new symptoms along the way? Researchers will also explore whether SARS-CoV-2 infection leads to changes that increase the risk of other conditions, such as lung, heart, or brain disorders.

The exact percentage of patients who contract COVID-19 and experience long-term sequalae is unknown, explained Art Wallace, MD, PhD, a professor of anesthesiology and perioperative care at the University of California, San Francisco and Chief of the Anesthesia Service at the Veterans Affairs Medical Center in San Francisco.

Estimates tend to range between 10% and 30%, but some research has arrived at even higher rates. For example, in one study, half of the patients continued to complain of health issues a full year after contracting COVID-19, he told First Report Managed Care.

After analyzing the private health care claims of nearly 2 million COVID-19 patients, FAIR Health—a national, independent not-for-profit organization—found that 23% had at least one post-COVID condition 30 days or more after initial diagnosis. The most common issues across all age groups (from most to least common) were pain, breathing difficulties, hyperlipidemia, fatigue, and hypertension.

According to the organization’s findings—which are published in a white paper titled “A Detailed Study of Patients with Long-Haul COVID”—post-COVID conditions occurred at greater levels in patients who experienced more severe cases of COVID-19. Of those hospitalized, 50% had a post-COVID condition compared with 28% of symptomatic (but not hospitalized) patients and 19% of asymptomatic patients.

In other work, a group of Penn State researchers reviewed 57 studies that included over 250,000 COVID-19 survivors. Their findings, detailed in a JAMA Network Open paper published October 13, 2021 (doi:10.1001/jamanetworkopen.2021.28568), revealed that more than half experienced PASC 6 months after recovery. According to the study, researchers also found that the most common long-term issues fell within the realm of mental health, pulmonary, and neurologic disorders.

“At the forefront of clinical care for acute COVID-19 are multiple guidelines, recommendations, and best practices that have been disseminated and prioritized for prevention and management,” researchers noted in their JAMA Network Open paper. “However, no clear guidelines are currently available for postinfectious care or recovery, and there is a notable dearth of information on strategies about how to assess and manage patients following their acute COVID-19 episode.”

They suggested that the clinical management of PASC calls for a whole-patient perspective and recommended one-stop multidisciplinary clinics to avoid multiple referrals to different specialists and to help encourage comprehensive care. Others, meanwhile, have pointed to the importance of community health centers considering Long COVID centers may not have the capacity to care for the massive numbers of people potentially impacted by PASC.

According to Kelli Tice, MD, senior medical director at Florida Blue, a comprehensive plan is needed to help reduce the burden of long-term complications and treatment. At the payer level, policy evaluations ought to include timely access to treatment, access to physical therapy, and mental health services for those who are at a heightened risk of anxiety, depression, or PTSD, she noted as part of the November NIHCM Foundation webinar.

Still others emphasize the need to reduce the likelihood of developing PASC in the first place. When asked what health plans should consider doing in 2022 to address the challenges posed by the long-term effects of COVID-19, Dr Leshem highlighted the importance of immunization and the use of protective equipment such as masks.

“As with all other medical issues,” he said, “prevention is far more effective than treatment.”