key: cord-0819032-8kv2tqkw
authors: Kwok, Chun Shing; Muntean, Elena‐Andra; Mallen, Christian D.
title: The impact of COVID‐19 on the patient, clinician, healthcare services and society: A patient pathway review
date: 2022-04-18
journal: J Med Virol
DOI: 10.1002/jmv.27758
sha: e6eca4e13b86d2767f5f21b994ae9dd2cda49261
doc_id: 819032
cord_uid: 8kv2tqkw

The spread of COVID‐19 infection has changed the world. Population‐based studies of COVID‐19 are limited because it is unknown why events happen or why certain outcomes occur. An alternative approach called the patient pathway review evaluates what happens to individuals in detail. In the “ideal” pathway patients with COVID‐19 will seek medical attention and COVID‐19 will be identified and they will either be admitted to hospital, managed in the community or they will self‐care. However, in the “real‐world” pathway, patients may delay seeking medical attention and it is variable who the patient decides to seek help from and some patients may be initially misdiagnosed. The eventual outcome will be recovery from the acute infection or death but there may be a spectrum of healthcare needs for patients from those who care for themselves in the community to those who are hospitalized and require intensive care. The patients may or may not have short‐ and long‐term adverse effects. People infected with COVID‐19 can take on different paths which depend on the patient's decision making, clinical decision making, and the patient's response to the infection. Desirable pathways are those where patients have good outcomes and also limit the transmission of the virus.

approach is looking at what happens to individuals in detail. This novel approach, known as the patient pathway review, 3 has not been applied to COVID-19 infections before. It has the distinct advantage that it considers possible paths that patients may take and then attempts to rationalize them by considering different perspectives such as that of the patient, clinician, health service, and society.

This review reports the patient pathway review with the starting point of a patient contracting COVID-19. It explores the consequence of the acute infection and the possible key events that take place. This is done in a systematic approach whereby an initial "ideal" pathway is defined with is then modified considering events that take place in "real-world" settings. The findings of the real-world settings are then discussed in the contact of the patient, clinician, healthcare service, and society perspective.

The first description of the patient pathway review has been published elsewhere. 3 This is described in brief below.

The starting point of this patient pathway review is that of a patient that is infected with COVID-19. The patient pathway review is also broken down into two aspects: the acute infection and potential short and long-term consequences after initial recovery.

The "ideal" pathway, from the patients' starting point is then developed considering the onset of symptoms, review by healthcare professionals, investigations, diagnosis, treatment, response for the acute infection, and subsequent outcomes.

From the "ideal" patient pathway, each stage will be systematically explored by considering undesirable realities in clinical practice such as patient's failure to recognize the significance of their symptoms, variability of the care delivered by healthcare professionals, and possible misdiagnosis. The systematic approach is defined by considering all stages of the pathway as opposed to just targeting certain stages of the pathway and ignoring others. This will be used to create a "real-world" pathway.

For the purposes of this evaluation, two assumptions are made. First, patients who are tested for COVID-19 who have the infection will test positive and we will not consider the real possibility that the test failed to detect the infection. Therefore, with the widespread availability of testing in many developed countries, all that is required for the determination of COVID-19 status is suspicion of the infection. Furthermore, while there is variation in the exact care individual patients with COVID-19 receive, once diagnosed the exact treatment algorithms for patients are beyond the scope of the current review but rather the approach of the patient being managed in the community, hospital, or intensive care is used with clinical severity of illness driving the transition between settings. The response is defined as either recovery from COVID-19 or death.

The development of potential adverse complications associated with COVID-19 after recovery will be discussed but a single pathway will be defined rather than first defining the "ideal" and then exploring it from a "real-world" approach.

Considering that one of the tenants of the patient pathway analysis is that there is usually a reason for why events take place, a systematic approach of considering the key perspectives was used to explain what and why events happen in the real-world pathway. First, would be the patient perspective including the reasoning for the decisions they made as well as their priorities.

Second, the clinician perspective is explored followed by that of the health service. Finally, the society agenda will be considered as public health measures and health policies can influence patient, clinician, and health service decision making.

3.1 | "Ideal" patient pathway after acute COVID-19 infection 3.2 | "Real-world" patient pathway after acute COVID-19 infection

The "real-world patient pathway evaluates what happens to patients in more detail (Figure 2 ). After contracting COVID-19 patients may or may not develop symptoms which may be a major driver regarding whether or not they will seek medical attention. There are also options in terms of who the person infected with COVID-19 will see for medical help. 

The pathway for patients after recovery from acute infection is shown in Figure 3 . Patients may have no short-or long-term adverse effects after COVID-19. The patient may have short-term adverse effects with or without long terms adverse effects including prolonged COVID-19 or no short-term adverse effects but longterm adverse effects. In terms of long-term effects, an important consideration is whether patients will die before developing the longterm adverse event.

It is well known that COVID-19 infection is potentially lifethreatening and as such most people would aim to avoid contracting the infection. However, once they are infected the aim shifts to overcoming the infection, alleviating any suffering from symptoms, and carrying on with independent living without any long-term adverse consequences. In the cases where patients are symptomatic understanding what the diagnosis underlying their ill-health may be of prime concern. Once the diagnosis is suspected or confirmed, the patient will consider whether or not they have symptoms that merit seeking medical advice. If a patient had a fever and cough, they may self-medicate with over-the-counter medications such as paracetamol. However, the collection of symptoms that may represent COVID-19 is diverse which includes fatigue, shortness of breath, anosmia, loss of appetite, myalgia, headache, and the patient may even be asymptomatic. 4 While symptoms may be the main driver for seeking medical attention, there may be other factors influencing the willingness to seek medical attention including whether they have the time or have other priorities/responsibilities, medical knowledge, and other factors including any concerns about contracting COVID-19 from seeking medical attention. One other factor which may impact decisions about seeking medical attention is the healthcare service and whether patients need to pay for care. There may be delays in seeking help in cases where there are initially mild symptoms because of the potential cost associated with healthcare in some countries.

It is not known whether delay in seeking medical attention affects the eventual outcome of acute COVID-19 infection. Aside from cases where patients die in the community from COVID-19 who did not receive any treatment, those patients who present to the hospital will have monitoring and treatment with appropriate escalation with clinical deterioration. Delays can also be contributed by delays in accessing diagnostic tests, delays related to misdiagnosis, and delays related to the volume of patients needing treatment. The exact care received will depend on the availability of healthcare and the extent to which it had to make adaptations to cope with COVID-19. It is expected that most patients will survive the illness but some may die especially those who are elderly and frail. 5, 6 The impact of COVID-19 infection extends beyond the individual but also to everyone around them and everyone they come into contact with. The possible responses are shown in Figure 4 which influence the likelihood of transmission to others which may be related to the severity of symptoms. People may increase contact with others, carry on with usual activities, reduce but not carry out full isolation or fully isolate themselves with as limited contact as possible. Patients may have a strong desire to limit potential spread to those living with them and isolate as much as possible.

Alternatively, patients especially those with very mild or no symptoms, may carry on with daily activities or increase contact with others.

From the clinician's perspective, it is important to protect themselves from being infected while also carrying out their duty to identify and treat the COVID-19 infection. In the efforts to minimize the chance 

The impact of COVID-19 on society is significant. The priority is to stop the infection from spreading and alleviating the burden of those affected by the illness and its consequences on society. The aim of the patient, in general, is to overcome the infection and minimize and potential long-term adverse effects. Some patients may also feel that it is important not to spread it to others, especially family members. Among mild cases which resolve, ideally the patient is able to isolate at home which minimizes the spread to other members of the public. While challenging to control especially when patients are asymptomatic, the risk of spreading the infection is expected to be high for patients who have COVID-19 but carry on doing the same level or increased levels of social contact. Isolation and not seeking medical attention can place the patient in danger of a poor outcome and even death in the community. In most cases, however, patients who deteriorate will call for help, and for some medical treatment may reverse the course of the illness. Nevertheless, for some patients, mortality will be the outcome regardless of intervention but it may place those looking after the patient and transporting the patient at risk of infection. keyboards, and so on, and some of the most important workers in COVID-19 exposed areas are the cleaners as they have a key role in reducing transmission. 9 It remains challenging to determine how exactly COVID-19 is transmitted on an individual level.

As a society, there are significant consequences on infection rates depending on government policies. Decisions to implement and stop lockdowns or restrictive measures can limit social contact but the use of a vaccine to achieve herd immunity is frequently acknowledged as the approach to combat the infection in the community. 10 However, a significant problem is a knowledge regarding the degree of protection of a vaccine. While mostly mild or asymptomatic, even fully vaccinated health care workers can have breakthrough infections. 11 The impact of vaccination and social restriction can alter the patient pathway so that fewer have severe symptoms and more will isolate and reduce contact with others when they have the infection.

There are clear pathways that are more desirable than others.

First is the patient who develops COVID-19 and decides to isolate in the community with minimal contact to others. Ideally, this patient recovers and does not transmit the infection and suffers no long-term consequences related to COVID-19, and is immune to subsequent exposure to infection. The next pathway that is to a degree favorable is that where a patient develops COVID-19 but requires supportive treatment in hospital or will die from the infection. While it is impossible to know whether a patient will need support to overcome the infection, there will be differences the extent to which this patient does or does not expose the public or healthcare profes- The COVID-19 pandemic at different stages has evolved in infection, spread, and disease. In addition, patients, clinicians, healthcare services, and society have learned lessons at every stage and devised appropriate responses. Therefore, it is important to be aware that the patient pathway might also evolve accordingly.

While the patient pathway approach provides a framework of what might happen to patients, it is limited because there is no understanding of how common each pathway is. However, the current approach has the value that it can be applied in any country, setting, or healthcare system. Another limitation of this approach is the defined ideal pathway. It may be argued that the pathway presented may not be the same if multiple clinicians with different experiences and practices were asked to define the ideal pathway. However, most developed countries will have patients cared for in different settings including hospitals and community care. The interesting thing about COVID-19 compared to other chronic conditions is that some patients will only have mild or no symptoms so they may not even know they had the infection so awareness of the group who do not seek medical attention is important. The consideration of guidelines may be of relevance to the ideal pathway however, the problem is that guidelines are only relevant to the countries which developed them. The other key limitation is that while we explore the possible outcomes in terms of long-and short-term effects or no effects of COVID-19 infection, there is insufficient data to comment yet on long-term effects as the virus spreading in humans have only been around for less than 2 years. KWOK ET AL. 

Squibb for academic support for a nonpharmacological atrial fibrillation screening trial but this is not related to this study.

Data sharing is not applicable.

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