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/></a></div><div class="bkr_bib"><h1 id="_NBK567265_"><span itemprop="name">COVID-19 rapid guideline: managing the long-term effects of COVID-19 (NG188)</span></h1><div class="subtitle">Evidence reviews 6 and 7: monitoring and referral</div><p><i>NICE Guideline, No. 188</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2020 Dec</span>.</div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2020.</div></div><div class="bkr_clear"></div></div><div id="niceng188er5.s1"><h2 id="_niceng188er5_s1_">Literature search</h2><p>NICE’s information services team identified relevant evidence through focused evidence searches between 22 and 28 October 2020 (see <a href="#niceng188er5.app3">appendix 3</a>). Additional studies were also considered from NICE surveillance up to 28 October 2020. Results from the literature searches and surveillance were screened using their titles and abstracts for relevance against the criteria from the protocol (see <a href="#niceng188er5.app2">appendix 2</a>). Four reviewers screened titles and abstracts. Having identified the evidence, four reviewers assessed the full text references of potentially relevant evidence to determine whether they met the inclusion criteria for this evidence review. All uncertainties were discussed amongst the reviewers and referred to an adviser if needed. See <a href="#niceng188er5.app4">appendix 4</a> for the study flow chart of included studies.</p><p>Healthcare Improvement Scotland knowledge management team also conducted a search to identify qualitative evidence to support the questions in this review. See <a href="https://www.sign.ac.uk/our-guidelines/managing-the-long-term-effects-of-covid-19" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Managing the long-term effects of COVID-19: the views and experience of patients, their families and carers</a> for more information. This review will be referred to in this document as ‘patient lived experience’.</p></div><div id="niceng188er5.s2"><h2 id="_niceng188er5_s2_">Methods and process</h2><p>This evidence review was developed using the methods and processes described in the <a href="/books/NBK567265/bin/niceng188er5_bm1.pdf">methods chapter</a>.</p></div><div id="niceng188er5.s3"><h2 id="_niceng188er5_s3_">Review question 6</h2><p>
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<b>What monitoring is helpful to assess deterioration or recovery in people with ongoing physical and mental health symptoms and problems carrying out usual activities, including work, education and leisure, following acute COVID-19?</b>
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</p><p>The review protocol is shown in <a href="#niceng188er5.app2">appendix 2</a>.</p></div><div id="niceng188er5.s4"><h2 id="_niceng188er5_s4_">Review question 7</h2><p>
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<b>What symptoms or signs indicate that referral to specialist care is needed for assessment or management of post-COVID-19 syndrome?</b>
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</p><p>The review protocol is shown in <a href="#niceng188er5.app2">appendix 2</a>.</p><p>Although the review questions 6 and 7 focused on post-COVID-19 syndrome, the panel concluded that referral and monitoring should not be confined to people who experience symptoms beyond 12 weeks. The evidence, patient experience and the panel’s experience pointed to the need for support for those experiencing ongoing symptoms beyond 4 weeks, to help avoid deterioration in people’s conditions and enable people to receive early preventative support.</p></div><div id="niceng188er5.s5"><h2 id="_niceng188er5_s5_">Included studies (for review questions 6 and 7)</h2><p>In total, 4,104 references were identified through the searches. Of these, 505 were included and ordered for full text assessment. A total of 58 references were included for the whole guideline, 3 of which were included for this review.</p><p>For review question 6, 3 references were included: a descriptive cohort study (<a class="bibr" href="#niceng188er5.app5.ref1" rid="niceng188er5.app5.ref1">D’Cruz et al, 2020</a>); a rapid narrative review with practice recommendations (Greenhalgh et al, 2020a); and practice recommendations in the form of a proposed pathway (<a class="bibr" href="#niceng188er5.app5.ref3" rid="niceng188er5.app5.ref3">Salawu et al, 2020</a>). See <a href="/books/NBK567265/table/niceng188er5.tab1/?report=objectonly" target="object" rid-ob="figobniceng188er5tab1">table 1</a> for more details on the identified studies.</p><p>For review question 7, 1 reference was included: the same rapid narrative review with practice recommendations (Greenhalgh et al, 2020a) as for review question 6. See <a href="/books/NBK567265/table/niceng188er5.tab1/?report=objectonly" target="object" rid-ob="figobniceng188er5tab1">table 1</a> for more details on the identified studies.</p><p>Due to the paucity of included evidence, additional information based on 3 references providing guidance (<a class="bibr" href="#niceng188er5.app5.ref5" rid="niceng188er5.app5.ref5">Barker-Davies et al, 2020</a>; <a class="bibr" href="#niceng188er5.app5.ref6" rid="niceng188er5.app5.ref6">COVID Trauma Response Working Group, 2020</a>; <a class="bibr" href="#niceng188er5.app5.ref7" rid="niceng188er5.app5.ref7">Spruit et al, 2020</a>) (See <a href="#niceng188er5.app5">appendix 5</a>) was also presented at the expert panel meeting.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng188er5tab1"><a href="/books/NBK567265/table/niceng188er5.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img" rid-ob="figobniceng188er5tab1"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng188er5.tab1"><a href="/books/NBK567265/table/niceng188er5.tab1/?report=objectonly" target="object" rid-ob="figobniceng188er5tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Included studies for review question 6: Monitoring to assess deterioration or recovery following acute COVID-19; and for review question 7: Referral to specialist post-COVID-19 syndrome services. </p></div></div></div><div id="niceng188er5.s6"><h2 id="_niceng188er5_s6_">Key results</h2><p>A descriptive cohort study, <a class="bibr" href="#niceng188er5.app5.ref1" rid="niceng188er5.app5.ref1">D’Cruz et al (2020)</a>, found that, in patients hospitalised with severe COVID-19 pneumonia, persistent symptoms, adverse mental health outcomes and physiological impairment are common 2 months following COVID-19, with chest radiograph being a poor marker of recovery (see <a href="#niceng188er5.app6">evidence table</a> for further details). Consequently, the authors recommended holistic face-to-face assessment to facilitate early recognition and management of post-COVID sequelae.</p><p><a class="bibr" href="#niceng188er5.app5.ref3" rid="niceng188er5.app5.ref3">Salawu et al (2020)</a> proposed a telerehabilitation pathway based on narrative review and local consensus. Salawu et al proposed assessment at 4- to 6-weeks post-discharge from hospital, identifying suitable patients who may benefit from a tele-rehabilitation programme; and providing them with the opportunity to enrol. At 12-weeks post-discharge, they proposed nurse-led assessment, including review of repeat chest X-ray (CXR). If a need for specialist rehabilitation was identified, they proposed referral to a multidisciplinary team (MDT) or alternatively discharge to primary care.</p><p><a class="bibr" href="#niceng188er5.app5.ref2" rid="niceng188er5.app5.ref2">Greenhalgh et al (2020)</a> provided practice recommendations based on a rapid narrative evidence review, combined with expert opinion. These were relevant for both monitoring and referral. The authors recommended approaches covering, depending on patient need and clinical findings, self-management including safety netting advice, and specialist referral to various services as appropriate. See results <a href="/books/NBK567265/table/niceng188er5.tab1/?report=objectonly" target="object" rid-ob="figobniceng188er5tab1">table 1</a> for further details.</p></div><div id="niceng188er5.s7"><h2 id="_niceng188er5_s7_">Subgroups</h2><p>No subgroup data were identified, although it should be noted that <a class="bibr" href="#niceng188er5.app5.ref1" rid="niceng188er5.app5.ref1">D’Cruz et al (2020)</a> used direct data from patients hospitalised with severe COVID-19 only.</p></div><div id="niceng188er5.s8"><h2 id="_niceng188er5_s8_">Strengths and limitations</h2><p>The risk of bias (RoB) for studies included in this review was assessed as high using the CASP critical appraisal checklist for cohort studies. See ‘quality’ for each study in <a href="#niceng188er5.app6">appendix 6</a>, Evidence tables.</p><p>No RoB could be undertaken for <a class="bibr" href="#niceng188er5.app5.ref3" rid="niceng188er5.app5.ref3">Salawu et al (2020)</a> or Greenhalgh et al (2020a) due to their not providing any direct evidence, and these publications may be considered at high risk of bias for the purposes of these review questions.</p></div><div id="niceng188er5.s9"><h2 id="_niceng188er5_s9_">Expert panel discussion - for both monitoring and referral</h2><p>This section describes how the expert panel considered the evidence in relation to the recommendations within the guidance.</p><div id="niceng188er5.s9.1"><h3>Relative value of different outcomes</h3><p>The relevant outcomes in the review protocol for monitoring were: Symptom improvement (or worsening); mortality; return to usual activities including work, education or leisure; quality of life and/or wellbeing; healthcare utilisation, for example number of visits to A&E; adverse events, e.g. side effects or unintended consequences. For referral, these outcomes were: number of referrals to specialist care and association between symptoms and signs and referrals to specialist care.</p><p>Outcomes of relevance were reported in <a class="bibr" href="#niceng188er5.app5.ref1" rid="niceng188er5.app5.ref1">D’Cruz (2020)</a>, but not in <a class="bibr" href="#niceng188er5.app5.ref2" rid="niceng188er5.app5.ref2">Greenhalgh (2020)</a> or <a class="bibr" href="#niceng188er5.app5.ref3" rid="niceng188er5.app5.ref3">Salawu et al (2020)</a>. Neither the included quantitative study or practice proposals were able to provide direct evidence on the specified PICO outcomes, for monitoring or referral.</p><p>The panel considered it was important to be able to effectively assess whether a patient had recovered or not, as part of monitoring/follow-up. Recovery would be considered as both symptom improvement - which might include links with quality of life and/or wellbeing - and an ability to return to usual activities, including work, education or leisure, or caring duties.</p></div><div id="niceng188er5.s9.2"><h3>Quality of the evidence</h3><p>The study populations in 2 of the 3 publications (<a class="bibr" href="#niceng188er5.app5.ref1" rid="niceng188er5.app5.ref1">D’Cruz et al, 2020</a>; <a class="bibr" href="#niceng188er5.app5.ref3" rid="niceng188er5.app5.ref3">Salawu et al, 2020</a>) focused on hospitalised patients, whereas the guideline is intended to cover both hospitalised and non-hospitalised people. Therefore, not all of the evidence included was generalisable to the wider population the panel wished to provide guidance for. It was acknowledged that the evidence was lacking for this review, with only a narrative review with practice recommendations, a single descriptive cohort study, and a practice model proposal included. Risk of bias was deemed to be high for the applicable study (<a class="bibr" href="#niceng188er5.app5.ref1" rid="niceng188er5.app5.ref1">D’Cruz et al, 2020</a>) and, as the next section describes, the panel used its own expertise and the patient experience data to supplement the lack of an evidence base for this review question.</p></div><div id="niceng188er5.s9.3"><h3>Trade-off between benefits and harms</h3><p>Whilst the evidence presented was insufficient to directly inform knowledge of benefits and harms of different monitoring and referral options, the panel used their experience to consider benefits and harms when drafting recommendations.</p><p>The panel noted that people may need to be referred urgently to acute services for physical health symptoms, or to psychiatric services, to prevent potentially serious consequences. The panel discussed appropriate tests which may need to be carried out as part of monitoring and follow-up; and agreed that these should be based on the person and their symptoms.</p><p>Based on limited evidence from one study in the review, the panel considered that a chest X-ray should be done if the person had not had one and there were continuing respiratory symptoms. The panel agreed that a chest X-ray should only be used as part of a holistic assessment to decide if referral or further care are needed. The panel also agreed that the lack of abnormal findings on a person’s chest X-ray should not be used as a reason to not refer the person for further assessment and rehabilitation. The panel discussed that the chest X-ray should be done (if needed) before 12 weeks to help rule out any other pathology before the person moves onto a treatment pathway for post-COVID-19 syndrome.</p><p>The panel discussed the patient lived experience evidence, describing how some people were not offered tests, and how others were denied referral due to not having a positive SARS-CoV-2 test result. Since many people with ongoing symptoms of COVID-19 or post-COVID-19 syndrome will not have been tested, particularly those who had COVID-19 illness earlier in the pandemic, the panel recommended that access to services should not be restricted by the need for a positive test.</p><p>The panel discussed the need for prompt referral to avoid delaying support for people. The panel drew on their own expertise to conclude that the earlier people received help, the more effective the interventions Qualitative evidence based on patient lived experience evidence potentially suggested that people left without support may suffer worse anxiety and poorer mental health.</p><p>Whilst evidence on monitoring was lacking, the panel agreed that monitoring is important to enable support to be adapted, if people’s symptoms or ability to carry out usual activities change. Evidence from patients’ lived experience highlighted the importance of follow-up to access further care. The panel did not want to limit monitoring to specific tests or symptoms, or to a particular timeframe, because people with long-term effects of COVID-19 have a wide range of care needs. The panel considered that monitoring should be tailored to each person. Based on their own experience and the patient lived experience evidence, the panel agreed on the value of people recording or tracking their symptoms, goals and progress. The panel were aware of digital tracking apps that could be used for self-monitoring and, although they acknowledged that these would not be suitable or accessible for everyone, they concluded that it would be useful to highlight these as potentially helpful approaches to recording symptoms.</p><p>Evidence from patients’ lived experience suggested that some people struggled to access appropriate care, and some had experienced fragmented care. The panel agreed on the need to improve integration and coordination of care across different services. The panel agreed that having regular multidisciplinary meetings would help share information more efficiently and allow professionals to make decisions quickly about tests and referral. The patient experience evidence also described how people could benefit from continuity of care, and the panel agreed this should be an aim for well-integrated services.</p><p>The panel discussed potential active monitoring of symptoms which would be considered below a threshold for referral. They concluded that whilst it is important not to miss these symptoms, neither should all decisions be based on them.</p><p>The panel noted that thresholds in screening tools, whilst capturing symptoms where they are high in one area, may miss so-called ‘pink flags’, whereby a patient may be experiencing multiple relatively low-level symptoms (e.g. a little shortness of breath, fatigue) which may still indicate very significant illness, needing multidisciplinary team (MDT) input. The panel therefore concluded that it was crucial for the referral to be based on a holistic assessment, not just a checklist of symptoms.</p><p>The panel also discussed the need to consider symptoms which would raise concern over a patient’s suitability for rehabilitation. Noting that, while patients will talk about their most current symptoms and be referred, symptoms might change by the time of the specialist/clinic appointment. It was discussed that patients may feel embarrassed if they have too many things to list, and not mention everything of potential significance. And so the panel agreed that it was essential for the healthcare professional to take these factors into account whenever carrying out assessments or rehabilitation.</p></div><div id="niceng188er5.s9.4"><h3>Implementation and resource considerations</h3><p>Much of the panel’s discussion on implementation and resource is covered in the expert discussion in the <a href="http://www.nice.org.uk/guidance/ng188/evidence" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">evidence review on service models</a>, which informed the recommendations on service organisation (rather than on monitoring and referral).</p><p>The panel discussed evidence from patients’ lived experience describing challenges for GPs of addressing a wide range of people’s symptoms, and a lack of coordinated care. As well as informing recommendations on service organisation, this informed recommendation 6.1 on planning and agreeing follow-up and monitoring.</p><p>The panel discussed the need for patient information, including advice for patients on trends in symptoms, management of symptoms, and when to call professionals. There needs to be good communication with patients, including how to manage subsequent symptoms if they occur. Panel members were concerned about the risk of patients who were not previously hospitalised becoming ‘lost’ in the system.</p><p>These discussions helped inform recommendations 6.2 (on shared decision-making) and 6.3 (on tailoring monitoring)</p><p>The panel noted there are likely to be waiting lists for referral into services and that people should be provided with clear information about what to expect, red flags and who to contact during this time. Patients could feel more empowered, with heightened sense of agency and control, if there are things they can do at home while waiting for referral, including potentially to aid their recovery.</p><p>The panel, considered, from their experience, that self-monitoring at home can be useful and is used in practice. However, the panel noted that it might not be suitable for everyone, and without the right information and support can cause unnecessary anxiety. People need good guidance to use equipment, interpret the results and understand when to contact a healthcare professional.</p><p>The panel therefore recommended (6.4) supported self-monitoring at home, if agreed as part of a person’s assessment, and combined with clear instructions including on when to seek further help.</p></div><div id="niceng188er5.s9.5"><h3>Other considerations</h3><p>The panel noted the need to also ensure that any symptom scores do not miss out other people who present with less common symptoms, with a concern over potential inequalities. They noted that vulnerable groups, such as older people and people who are isolated may need proactive patient follow-up, together with accessible advice.</p><p>The panel discussed the need for co-ordinated care and communication when referring to specialist services.</p></div></div><div id="niceng188er5.app1"><h2 id="_niceng188er5_app1_">Appendix 1. Methods used to develop the guidance</h2><p>Please see the <a href="/books/NBK567265/bin/niceng188er5_bm1.pdf">methods chapter</a> for details on how this guideline was developed.</p></div><div id="niceng188er5.app2"><h2 id="_niceng188er5_app2_">Appendix 2. Review protocols</h2><div id="niceng188er5.app2.s1"><h3>Review question 6. What monitoring is helpful to assess deterioration or recovery in people with ongoing physical or mental health symptoms and problems carrying out usual activities, including work, education and leisure, following acute COVID-19?</h3><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng188er5app2tab1"><a href="/books/NBK567265/table/niceng188er5.app2.tab1/?report=objectonly" target="object" title="Table" class="img_link icnblk_img" rid-ob="figobniceng188er5app2tab1"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng188er5.app2.tab1"><a href="/books/NBK567265/table/niceng188er5.app2.tab1/?report=objectonly" target="object" rid-ob="figobniceng188er5app2tab1">Table</a></h4><p class="float-caption no_bottom_margin">4 to 12 weeks from onset of acute COVID-19 illness 12 weeks from onset of acute COVID-19 illness</p></div></div></div><div id="niceng188er5.app2.s2"><h3>Review question 7. What symptoms or signs indicate that referral to specialist care is needed for assessment or management of post-COVID-19 syndrome?</h3><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng188er5app2tab2"><a href="/books/NBK567265/table/niceng188er5.app2.tab2/?report=objectonly" target="object" title="Table" class="img_link icnblk_img" rid-ob="figobniceng188er5app2tab2"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng188er5.app2.tab2"><a href="/books/NBK567265/table/niceng188er5.app2.tab2/?report=objectonly" target="object" rid-ob="figobniceng188er5app2tab2">Table</a></h4><p class="float-caption no_bottom_margin">4 to 12 weeks from onset of acute COVID-19 illness 12 weeks from onset of acute COVID-19 illness</p></div></div></div></div><div id="niceng188er5.app3"><h2 id="_niceng188er5_app3_">Appendix 3. Literature search strategy</h2><div id="niceng188er5.app3.s1"><h3>Database strategies</h3><p>Please refer to the <a href="/books/NBK567265/bin/niceng188er5_bm2.pdf">search history record</a> for full details of the search.</p></div></div><div id="niceng188er5.app4"><h2 id="_niceng188er5_app4_">Appendix 4. Study flow diagram</h2><div id="niceng188er5.app4.fig1" class="figure"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Image%20niceng188er5app4f1&p=BOOKS&id=567265_niceng188er5app4f1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img src="/books/NBK567265/bin/niceng188er5app4f1.jpg" alt="Image niceng188er5app4f1" class="tileshop" title="Click on image to zoom" /></a></div></div></div><div id="niceng188er5.app5"><h2 id="_niceng188er5_app5_">Appendix 5. Included studies</h2><div id="niceng188er5.app5.rl.r1"><h3>Review question 6. Monitoring</h3><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng188er5.app5.ref1">D’Cruz
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RF, Waller
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MD, Perrin
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F, et al. Chest radiography is a poor predictor of respiratory symptoms and functional impairment in survivors of severe COVID-19 pneumonia. ERJ Open Res
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2020; in press (10.1183/23120541.00655-2020). [<a href="/pmc/articles/PMC7585700/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7585700</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/33575312" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33575312</span></a>] [<a href="http://dx.crossref.org/10.1183/23120541.00655-2020" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">CrossRef</a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng188er5.app5.ref2">Greenhalgh, T., Knight, M.
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et al. (2020) Management of post-acute COVID-19 in primary care. BMJ
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2020;370:m3026
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10.1136/bmj.m3026
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[<a href="https://pubmed.ncbi.nlm.nih.gov/32784198" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32784198</span></a>] [<a href="http://dx.crossref.org/10.1136/bmj.m3026" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">CrossRef</a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng188er5.app5.ref3">Salawu, Abayomi, Green, Angela, Crooks, Michael G
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et al. (2020) A Proposal for Multidisciplinary Tele-Rehabilitation in the Assessment and Rehabilitation of COVID-19 Survivors. International journal of environmental research and public health
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17(13) [<a href="/pmc/articles/PMC7369849/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7369849</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32645876" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32645876</span></a>]</div></p></li></ul></div><div id="niceng188er5.app5.rl.r2"><h3>Review question 7. Referral</h3><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng188er5.app5.ref4">Greenhalgh, T., Knight, M.
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et al. (2020) Management of post-acute COVID-19 in primary care. BMJ
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2020;370:m3026
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10.1136/bmj.m3026
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[<a href="https://pubmed.ncbi.nlm.nih.gov/32784198" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32784198</span></a>] [<a href="http://dx.crossref.org/10.1136/bmj.m3026" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">CrossRef</a>]</div></p></li></ul></div><div id="niceng188er5.app5.rl.r3"><h3>For reference: Relevant guidance not included formally in evidence review</h3><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng188er5.app5.ref5">Barker-Davies
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RM, O’Sullivan
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O, et al. Br J Sports Med
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2020;54:949–959.
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[<a href="/pmc/articles/PMC7418628/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7418628</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32475821" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32475821</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng188er5.app5.ref6">COVID Trauma Response Working Group
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Rapid Guidance: Screening and active monitoring for post-traumatic stress disorder (PTSD) and other mental health consequences in people recovering from severe COVID-19 illness. COVID Trauma Response Working Group. Version 1.5 (June
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25, 2020). Available at: <a href="https://www.traumagroup.org/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.traumagroup.org/</a> (checked 11/12/20).</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng188er5.app5.ref7">Spruit
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MA, Holland
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AE, Singh
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SJ, et al. COVID-19: Interim Guidance on Rehabilitation in the Hospital and Post-Hospital Phase from a European Respiratory Society and American Thoracic Society-coordinated International Task Force. Eur Respir J
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2020; in press (10.1183/13993003.02197-2020). [<a href="/pmc/articles/PMC7427118/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7427118</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32817258" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32817258</span></a>] [<a href="http://dx.crossref.org/10.1183/13993003.02197-2020" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">CrossRef</a>]</div></p></li></ul></div></div><div id="niceng188er5.app6"><h2 id="_niceng188er5_app6_">Appendix 6. Evidence tables</h2><div id="niceng188er5.app6.s1"><h3>Review questions 6. Monitoring; and 7: Referral</h3><p id="niceng188er5.app6.et1"><a href="/books/NBK567265/bin/niceng188er5-app6-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">D’Cruz 2020 (Monitoring only)</a><span class="small"> (PDF, 197K)</span></p><p id="niceng188er5.app6.et2"><a href="/books/NBK567265/bin/niceng188er5-app6-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Greenhalgh 2020 (Monitoring and referral)</a><span class="small"> (PDF, 200K)</span></p><p id="niceng188er5.app6.et3"><a href="/books/NBK567265/bin/niceng188er5-app6-et3.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Salawu 2020 (Monitoring only)</a><span class="small"> (PDF, 154K)</span></p></div></div><div id="niceng188er5.app7"><h2 id="_niceng188er5_app7_">Appendix 7. Excluded studies</h2><p>Please refer to the full list of <a href="/books/NBK567265/bin/niceng188er5_bm3.pdf">excluded studies</a> for this guideline.</p></div></div><div class="fm-sec"><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2020.</div><div class="small"><span class="label">Bookshelf ID: NBK567265</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/33555769" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">33555769</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng188er5tab1"><div id="niceng188er5.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Included studies for review question 6: Monitoring to assess deterioration or recovery following acute COVID-19; and for review question 7: Referral to specialist post-COVID-19 syndrome services</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK567265/table/niceng188er5.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng188er5.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng188er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng188er5.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Country, study design, dates</th><th id="hd_h_niceng188er5.tab1_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population (n)</th><th id="hd_h_niceng188er5.tab1_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Monitoring/ referral aspects</th><th id="hd_h_niceng188er5.tab1_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Timeframe</th><th id="hd_h_niceng188er5.tab1_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Main results</th></tr></thead><tbody><tr><td headers="hd_h_niceng188er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng188er5.app5.ref1" rid="niceng188er5.app5.ref1">D’Cruz 2020</a>
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</td><td headers="hd_h_niceng188er5.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">UK, Descriptive cohort study (prospective) June to July 2020</td><td headers="hd_h_niceng188er5.tab1_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">119 COVID-19 survivors previously hospitalised with PCR-confirmed severe COVID-19 pneumonia (mean age 58.7)</td><td headers="hd_h_niceng188er5.tab1_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Chest radiography to assess recovery following respiratory symptoms</td><td headers="hd_h_niceng188er5.tab1_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>4 to 6 weeks post-discharge</p>
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<p>Median (IQR) times between hospital admission and discharge to follow-up assessment were 76 (71 to 83) days and 61 (51 to 67) days, respectively</p></td><td headers="hd_h_niceng188er5.tab1_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Persistent symptoms, adverse mental health outcomes and physiological impairment are common, 2 months after severe COVID-19.</p>
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<p>Follow-up chest radiograph is a poor marker of recovery. (refer to <a href="#niceng188er5.app6">evidence table</a>).</p>
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<p>Authors recommend: ’Holistic face-to-face (or virtual) assessment’ to facilitate early recognition and management of post-COVID sequelae, in this group</p></td></tr><tr><td headers="hd_h_niceng188er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Greenhalgh 2020a</td><td headers="hd_h_niceng188er5.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">UK, Overarching practice recommendations for primary care, based on narrative review and expert opinion</td><td headers="hd_h_niceng188er5.tab1_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Patients who have a delayed recovery from an episode of COVID-19 managed in community or standard hospital ward</td><td headers="hd_h_niceng188er5.tab1_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Pulmonary/Neuro/Cardiology/Mental health referral</p>
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<p>Symptom monitoring in primary care</p></td><td headers="hd_h_niceng188er5.tab1_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Post-acute COVID-19 defined as >=3 weeks from onset of first symptoms, and chronic COVID-19 as extending beyond 12 weeks</td><td headers="hd_h_niceng188er5.tab1_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Authors recommend: Self-management: Daily pulse oximetry and safety netting advice</p>
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<p>Authors recommend:</p>
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<p>Safety netting and referral:</p>
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<p>Patient should seek medical advice if concerned e.g. worsening breathlessness, PaO2<96%, unexplained chest pain, new confusion, focal weakness.</p>
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<p>Specialist referral based on clinical findings, e.g. to Respiratory, Cardiology, or Neurology</p>
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<p>For patients who have had a significant respiratory illness: community follow-up with a chest X-ray at 12 weeks and referral for new, persistent, or progressive symptoms.</p>
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<p>For those with evidence of lung damage (such as persistent abnormal chest X-ray and oximeter readings), referral to a respiratory service.</p>
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<p>Authors suggest that subsequent early referral to pulmonary rehabilitation probably aids recovery.</p></td></tr><tr><td headers="hd_h_niceng188er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng188er5.app5.ref3" rid="niceng188er5.app5.ref3">Salawu (2020)</a>
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</td><td headers="hd_h_niceng188er5.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">UK, Narrative review and proposed pathway based on authors’ clinical experience</td><td headers="hd_h_niceng188er5.tab1_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Patients previously hospitalised with COVID-19 (both ICU and non-ICU patients)</td><td headers="hd_h_niceng188er5.tab1_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Use of remote monitoring to assess rehabilitation needs.</p>
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<p>Assessment to include nurse-led assessment, including review of repeat chest X-ray</p></td><td headers="hd_h_niceng188er5.tab1_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">4 to 6 weeks and 12 weeks post discharge</td><td headers="hd_h_niceng188er5.tab1_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Authors recommend:</p>
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<p>Onward referral to MDT rehabilitation if a need for specialist rehabilitation is identified, or discharge to primary care</p></td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng188er5app2tab1"><div id="niceng188er5.app2.tab1" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK567265/table/niceng188er5.app2.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng188er5.app2.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Criteria</th><th id="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Notes</th></tr></thead><tbody><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Adults and children who are experiencing new or ongoing symptoms:
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<ul><li class="half_rhythm"><div>4 to 12 weeks from onset of acute COVID-19 illness</div></li><li class="half_rhythm"><div>12 weeks from onset of acute COVID-19 illness</div></li></ul></td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Interventions</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any type of monitoring for example, frequency of follow-ups</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparators</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any or no comparator</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Symptom improvement (or worsening)</div></li><li class="half_rhythm"><div>Mortality</div></li><li class="half_rhythm"><div>Return to usual activities including work, education or leisure</div></li><li class="half_rhythm"><div>Resumption of (informal) caring arrangements</div></li><li class="half_rhythm"><div>Quality of life and/or Wellbeing</div></li><li class="half_rhythm"><div>Healthcare utilisation, for example number of visits to A&E or increased need for social care support</div></li><li class="half_rhythm"><div>Adverse events, e.g. side effects or unintended consequences</div></li></ul></td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Settings</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Subgroups</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Groups as defined in the EIA for example, age, sex, ethnicity</div></li><li class="half_rhythm"><div>Diagnosis of COVID-19 (e.g. confirmed or high clinical suspicion)</div></li><li class="half_rhythm"><div>Duration of symptoms</div></li></ul></td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study types</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Any</p>
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<p>The following study design types for this question are preferred. Where these studies are not identified, other study designs will be considered.
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<ul><li class="half_rhythm"><div>RCTs</div></li><li class="half_rhythm"><div>Systematic reviews of RCTs and observational studies</div></li><li class="half_rhythm"><div>Prospective and retrospective observational studies</div></li></ul></p></td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Countries</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Timepoints</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Other exclusions</td><td headers="hd_h_niceng188er5.app2.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Management of acute COVID-19 (symptoms experienced for up to 4 weeks)</div></li><li class="half_rhythm"><div>Management of other conditions with similar features to post-COVID-19 syndrome, for example post-intensive care syndrome and myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome (ME/CFS)</div></li><li class="half_rhythm"><div>Management of end-organ damage, which already has defined pathways of care.</div></li></ul></td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng188er5app2tab2"><div id="niceng188er5.app2.tab2" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK567265/table/niceng188er5.app2.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng188er5.app2.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Criteria</th><th id="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Notes</th></tr></thead><tbody><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Adults and children who are experiencing new or ongoing symptoms:
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<ul><li class="half_rhythm"><div>4 to 12 weeks from onset of acute COVID-19 illness</div></li><li class="half_rhythm"><div>12 weeks from onset of acute COVID-19 illness</div></li></ul></td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Exposure</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Critical symptoms or signs (e.g. red flags) that lead to referral</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparators</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Not applicable</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Number of referrals to specialist care</div></li><li class="half_rhythm"><div>Association between symptoms and signs and referrals to specialist care</div></li></ul>
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</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Settings</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Subgroups</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Groups as defined in the EIA for example, age, sex, ethnicity</div></li><li class="half_rhythm"><div>Diagnosis of COVID-19 (e.g. confirmed or high clinical suspicion)</div></li><li class="half_rhythm"><div>Duration of symptoms</div></li></ul>
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</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study types</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Any</p>
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<p>The following study design types for this question are preferred. Where these studies are not identified, other study designs will be considered.</p>
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<p>Preferred:
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<ul><li class="half_rhythm"><div>Systematic reviews of cohort studies</div></li><li class="half_rhythm"><div>Cohort studies (prospective or retrospective)</div></li><li class="half_rhythm"><div>Cross-sectional studies</div></li></ul></p></td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Countries</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Timepoints</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Any</td></tr><tr><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Other exclusions</td><td headers="hd_h_niceng188er5.app2.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">See scope</td></tr></tbody></table></div></div></article><article data-type="fig" id="figobniceng188er5app4fig1"><div id="niceng188er5.app4.fig1" class="figure"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Image%20niceng188er5app4f1&p=BOOKS&id=567265_niceng188er5app4f1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img data-src="/books/NBK567265/bin/niceng188er5app4f1.jpg" alt="Image niceng188er5app4f1" class="tileshop" title="Click on image to zoom" /></a></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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