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Utilización de recursos sanitarios y sociales por parte de personas con COVID

persistente y su relación con la sintomatología persistente: estudio

secundario descriptivo y correlacional

The use of health and social resources by people with persistent COVID and

its relationship with persistent symptomatology: A secondary descriptive and

correlational study.

Sergio Lafita Mainz 1,2, Natalia Formento Marín1,2, Susana Aldecoa Landesa3, Diego Oliván2, Mª

Mar Martínez Pecharroman1,2*, Raquel Refusta Ainaga1,2 & Isabel Blasco González 1,2.

1. Servicio Aragonés de Salud. España.

2. Instituto de Investigación Sanitaria de Aragón.

3. Servicio Gallego de Salud (SERGAS).

* Corresponding author: marmarpec@gmail.com

Recibido 2023-05-15. Aceptado 2023-08-08

Resumen

Introducción: Aproximadamente, 10% de los pacientes que tuvieron una infección por SARS-COV-2,

presentan una sintomatología persistente, que les ha mermado su calidad de vida. Esto es

especialmente relevante en personas que se contagiaron durante la primera ola. El objetivo de este

estudio es analizar el consumo de recursos sanitarios y sociales por parte de personas con COVID

persistente y su relación con la sintomatología persistente que presentan. Metodología: Estudio

descriptivo transversal y correlacional en el que se recogen datos de pacientes con COVID persistente

recogiendo variables sociodemográficas, clínicas (número de síntomas persistentes), y de consumo de

recursos sanitarios y sociales. Resultados: Los participantes en este estudio muestran una alta

afectación reflejado en la gran cantidad de síntomas residuales que presentan (media 16,47 síntomas).

Por ello, hay un incremento considerable en la utilización de los recursos sanitarios, sociales y legales

tanto públicos como privados. Los servicios de Atención Primaria son los que más se han utilizado por

parte de estos pacientes.

Conclusión: Es necesaria una planificación oportuna de recursos y servicios centrados en el paciente

para la atención posterior a la COVID-19.

Palabras clave: COVID persistente; sintomatología persistente; recursos sanitarios; recursos sociales.

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Abstract

Introduction: Approximately 10% of all patients infected with SARS-COV-2 experience persistent

symptoms that reduce their quality of life. This is especially relevant in individuals who were infected

during the first COVID-19 wave. This study analyzes the use of health and social resources by

individuals suffering from persistent COVID and its relationship with their persistent symptomatology.

Methodology: Cross-sectional descriptive and correlational study in which data are collected from

patients with persistent COVID, considering sociodemographic and clinical variables (number of

persistent symptoms), and consumption of health and social resources. Results: Participants in this

study experienced a high affectation, as reflected by the large number of residual symptoms that they

experienced (mean of 16.47 symptoms). Therefore, a large increase is seen in the use of public and

private health, social, and legal resources. Primary care services are the most frequently used by these

patients.

Conclusion: Timely planning of patient-centered resources and services for post-COVID-19 care is

needed.

Keywords: Long COVID; persistent symptomatology; healthcare resources; social resources.

INTRODUCTION

COVID-19 disease caused by the SARS-CoV-2 severe acute respiratory syndrome has had a devastating

global impact, resulting in an unprecedented health, social, and economic crisis. The initiation of

vaccination was a turning point in the pandemic’s evolution on a health, economic, and social level.

However, more than 10% of the patients who have overcome the disease experienced persistent

symptoms within weeks of their recovery (National Statistics Office, n.d.). Research and care for this

large population group who have had COVID-19 and continue to experience disabling symptoms is a

social responsibility.

Persistent COVID is the syndrome occurring in certain patients who have had a COVID-19 infection

and who experience persistent symptoms, sometimes chronic, resulting in a poor quality of life

(National Statistics Office, n.d.).

Some individuals who suffered from even “mild” COVID-19 infections continue to experience

persistent or cyclical symptoms, such as chest pain and palpitations, shortness of breath, muscle and

joint pain, headaches, cognitive impairment ('mental fog'), neuropathy and paresthesia, and fatigue

(Alwan, 2020; Carfì, Bernabei, & Landi, 2020; Townsend et al., 2020). Similar symptoms (chronic

fatigue, pain, weakness, depression, and sleep disturbance) have been seen to follow SARS infection

(Moldofsky & Patcai, 2011). These symptoms appear to be cyclical and variable (Troyer, Kohn, & Hong,

2020; Varatharaj et al., 2020). The most common are cognitive and neurological (Ellul et al., 2020),

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respiratory (Fraser, 2020), fatigue, cardiovascular (Akhmerov & Marbán, 2020), dermatological, and

gastrointestinal symptoms (Assaf, Davis, & McCorkell, 2020). It is unknown how long these symptoms

may persist, or the preferred treatment of the same.

In Spain, patients and patient associations’ for those experiencing persistent COVID have complained

of the lack of resources allocated to research on this pathology, especially as compared to the

resources allocated to the management and control of acute COVID. Some have associated this poor

response to persistent COVID with a lack of resources (Salto, 2022).

Studies using population-based analyses during the first 6 months of the pandemic (February to

August 2020) have shown that a large proportion of individuals infected with SARS-COV-2 during the

first wave had longer-term consequences. These data already indicated that, with millions infected

worldwide, the timely planning of patient-centered resources and services for post-COVID-19 care

would be necessary (Menges et al., 2021).

Few studies have analyzed the use of health and social resources by people with persistent COVID

(Abdullah et al., 2023; Binka et al., 2022; Koumpias, Schwartzman, & Fleming, 2022; Menges et al.,

2021; Miller et al., 2023; Tene, Bergroth, Eisenberg, David, & Chodick, 2023). Normally, large

databases have been used and few studies have examined the association with variables such as the

number of persistent symptoms or sociodemographic variables of those affected by this syndrome.

Therefore, this study aims to analyze the consumption of health and social resources by individuals

with persistent COVID and its relationship with their persistent symptomatology.

METHODS

Design

Cross-sectional descriptive and correlational study. Data were collected from patients suffering from

persistent COVID-19, including sociodemographic, clinical, health, and social resource consumption

variables. Data collection took place in March 2022.

This study is part of a randomized clinical trial registered in the ISRCTN database under reference

number ISRCTN91104012 (Samper-Pardo et al., 2022). Its objective is to analyze the effectiveness and

cost-effectiveness of an intervention using a primary health care APP. The study was developed in an

autonomous community of northern Spain.

Participants, sample, and sample size

The study population was post-COVID-19 patients aged 18 years or older and attended by Primary

Health Care (PHC) services.

The inclusion criteria were being over 18 years of age, having experienced a SARS-COV-2 infection

diagnosed by their family doctor or specialized services for more than three months at the time of

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recruitment and having persistent symptoms, or having a diagnosis of persistent COVID in their clinical

history.

Exclusion criteria were not having a positive COVID-19 diagnostic test; having a diagnosis of severe

uncontrolled disease; having a significant risk of suicide; pregnancy and lactation; participation in a

clinical trial during the past six months; undergoing structured rehabilitative or psychotherapeutic

treatment by healthcare professionals and the presence of any medical, psychological, or social

problems that could significantly interfere with the patient's participation in the study.

Patients were recruited by Primary Health Care professionals, but patients from the Long COVID

Association of Aragon (Spain) also participated.

A convenience sample was used. The necessary sample size was calculated for the clinical trial

(Samper-Pardo et al., 2022). In this study, the main outcome was quality of life; therefore, the pre-

post score difference of the SF-36 instrument was used, considering the value of the highest possible

standard deviation (SD) and a minimum expected difference of 19.3 points for the pre-post rating. A

power of 95% was accepted in a two-sided contrast, along with a risk of 0.05 and a maximum dropout

rate of 10%. The minimum required sample size was 78 subjects, but 100 subjects finally participated

in the study, exceeding the necessary sample size. Of these participants, 20 were men and 80 were

women.

Variables and instruments

Sociodemographic variables, clinical variables related to persistent symptomatology, and the use of

health, social, and legal resources were collected for this study.

- The following socio-demographic variables were considered: gender (man, woman, other),

age, civil status (married or in relationship/single, separated, divorced, or widowed),

education (no studies or primary studies/secondary or university studies), and occupation

(employee, unemployed, employee with temporary work disability (TWD), permanent

disability, retired, others).

- Clinical variables related to post-COVID-19 infection: time since the infection (months),

number of residual symptoms, and severity of these symptoms measured using the Analogue

Visual Scale (36). Residual symptoms included: gastrointestinal symptoms, loss of smell, loss

of taste, blurred vision, eye problems (increased diopter, dryeyes, conjunctivitis), tiredness or

fatigue, cough, fever (over 38°C), low-grade fever (37°C - 38°C), chills or shivering without

fever, bruising, myalgia, headaches, sore throat, dyspnea, drowsiness, dizziness, tachycardia,

orthostatic hypotension, joint pain, chest pain, back pain (cervical, dorsal, or lumbar),

neurological symptoms (tingling, spasms, etc. ), memory loss, confusion or brain fog, short

attention and concentration span, loss of libido or erectile dysfunction, altered menstrual

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cycle, urinary symptoms (infections, overactive bladder), hair loss and other “residual”

symptoms.

- For resource use, the Client Service Receipt Inventory (Knapp, 2001) was used, collecting

information on the entire range of services and supports related to the persistent COVID

pathology used by study participants. It retrospectively collects data on the use of services

over the past 6 months (e.g., rates of use of individual services, mean intensity of service use,

and rates of accommodation use over time). It collects data on the use of hospital services

(emergency and hospitalization), primary care professionals, medical specialties, social

services (home-helpers, association of affected persons, lawyer visits, court appearances,

medical court), complementary tests, absenteeism, and attendance. The validated Spanish

version (Vázquez-Barquero et al., 1997) was used.

Statistical analysis

The sample size allowed the use of parametric methods since, in large samples, although the data

does not follow a normal distribution, the statistics tend to be normal (Lubin Pigouche, Maciá Antón,

2005). First, a descriptive analysis of the sample was performed for the study variables, using

frequencies and percentages for categorical variables, and means and standard deviation (SD) for

continuous variables. To analyze the correlation between the number of symptoms and the variables

of the use of health, social and legal resources, the Pearson P statistic was used. Statistical analysis

was performed using IBM SPSS and R 4.0.5. [60] and results were considered significant when the p-

value was equal to or less than 0.05.

Ethical considerations

The Clinical Research Ethics Committee of Aragón granted ethics approval (PI21/454). Procedures

were carried out in compliance with the ethical standards of the previously mentioned committee

and according to the 1975 Declaration of Helsinki (revised in 2008). All of the subjects signed an

informed consent form; their data wereanonymized and will only be used for this study.

RESULTS

100 individuals participated, of whom 80 were women and 20 were men. The mean age was 48.28

years (SD: 9.26, range: 29-72). Table 1 presents the description of the total sample, concerning

sociodemographic and clinical variables. The profile of the participant was a woman, 48 years of age,

married, with secondary school studies or a university education, employed or with temporary work

incapacity. The time since the infection was 16.12 months (SD 6.34), and the most prevalent

persistent symptomatology was fatigue (98%), cognitive symptomatology (between 71 and 89%),

muscle and joint pain (between 74 and 85%), and dyspnea (60%).

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Table 1

Sample description in terms of sociodemographic, clinical variables, and persistent symptoms.

Variables

Total sample=100

N(%)

mean (SD)

GENDER

Men

Women

20 (20%)

80 (80%)

AGE*

48.28 (9.26)

MARITAL STATUS

Married or in arelationship

Single, separated, widowed

70 (70%)

30 (30%)

EDUCATIONAL LEVEL

Without studies or primary studies

Secondary or university studies

9 (9%)

91 (91%)

OCCUPATION

Employed

Unemployed

TWD

Retired

Others

46 (46.9%)

5 (5.1%)

37 (37.8%)

9 (9.2%)

1 (1%)

TIME SINCE THE INFECTION (months) *

16.12 (6.34)

NUMBER OF PERSISTENT SYMPTOMS*

16.47 (5.99)

PERSISTENT SYMPTOMS (yes%)

Gastrointestinal symptoms

Loss of smell

Loss of taste

Blurred vision

Eye problems (dry eyes, conjunctivitis)

Tiredness or fatigue

Cough

Fever (over 38°C)

Low-grade fever (37°C - 38°C)

Chills or shivering without fever

Bruising

Myalgia

Headaches

Sore throat

Dyspnea

66%

51%

48%

51%

31%

98%

49%

20%

27%

39%

22%

85%

70%

42%

60%

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Drowsiness

Dizziness

Tachycardia

Orthostatic hypotension

Joint pain

Chest pain

Back pain (cervical, dorsal, lumbar)

Neurological symptoms (tingling, spasms, etc.)

Memory loss

Confusion or brain fog

Short attention and concentration span

41%

60%

57%

20%

74%

52%

58%

59%

81%

71%

89%

SD: Standard Deviation; TWD: Temporary Work Disability.

All variables are shown in percentages except for continuous variables*, which are shown in means and standard

deviation.

Regarding the use of health services, Table 2 shows that 48% used hospital emergency services and

6% had to be hospitalized. Family medicine services of the public health system were the most widely

used (93%) and 43% were referred to a specialized public medicine service. The most frequent

referrals were made to pneumology, neurology, internal medicine, and digestive medicine. Eleven

percent visited a public health psychiatrist, but only 7% visited a public health psychologist, while 11%

went to a private psychologist. Eleven percent had to attend a public medical court. As for diagnostic

tests, the most frequent were blood tests (56%) and X-rays (30%).

Table 2

Use of health and social services and number of times used.

PERCENTAGE OF INDIVIDUALS

USING SERVICES

HOW MANY TIMES WAS THIS

SERVICE USED?

Mean (SD)

HOSPITAL HEALTH CARE

Hospital emergencies (yes%)

Hospital admissions (yes%)

Days of hospitalization

48%

1.65 (1,21)

1 (0)

2.40 (2.60)

PRIMARY HEALTH CARE (yes%)

Public family medicine

Private family medicine

Public Family Nurse Practitioner

Private Family Nurse Practitioner

Public Social Work

Private Social Work

93%

11%

24%

8.53 (7.31)

4.54 (3.07)

3.58 (4.51)

1.75(0.95)

2.00 (1.82)

SPECIALIZED HEALTH CARE (yes%)

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Public health psychiatrist

Psychiatrist in private healthcare

Public health psychologist

Psychologist in private healthcare

Public/private psychiatric nurse

Public group psychotherapy

Private group psychotherapy

Public specialized medicine 1

Private specialized medicine

Public specialized medicine 2

Public specialized medicine 3

Private specialty medicine 3

Alternative medicine

Optician private care

Optician public care

Podiatry private care

11%

43%

33%

36%

18%

23%

16%

17%

1.72 (1.55)

2.83 (1.83)

1.71 (0.95)

7.63 (6.21)

29.50 (37.47)

24.00 (22.62)

1.62 (1.29)

1.90 (1.30)

1.27 (0.51)

3.16 (5.80)

1.17 (0.49)

1.56 (1.09)

3.00 (2.00)

1.00 (0.00)

1.52 (1.00)

2.75 (2.25)

SOCIAL AND LEGAL SERVICES (yes%)

Public home assistant

Private home assistant

Association of affected people

Visits to public lawyers

Visits to private lawyers

Public medical court

Private medical court

11%

12.5 (16.26)

2.00 (0.81)

5.00

1.75 (0.70)

1.09 (0.30)

1.00 (0)

DIAGNOSTIC TESTS (yes%)

Blood tests

Audiometry

Bone densitometry

Electrocardiogram

Ultrasound

Ultrasound-Dopler

Electromyogram

Spirometry

Gammagraphy

Digestive fibrogastroscopy

Stress test

Magnetic resonance imaging

X-ray

Computed Tomography Scan

Other

56%

19%

18%

11%

13%

30%

18%

42%

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SD: Standard Deviation

Regarding the role of work, 72% were in a situation of occupational incapacity during the last year. Of

those who wereactive, over the last month, they had to leave their tasks halfwayat 11.86 days (SD

13.89), and the quality of their work was reduced by 13.81 days (SD 19.12). On a scale of 0 to 100,

with 0 being the lowest and 100 being the highest value, the quantity of work was 63.50 (SD 35.86)

and the quality of work was 71.94 (SD 25.64).

Table 3

Temporary work incapacity status, absenteeism, and attendance during the last 12 months.

MEAN (SD)

Days you have been on sick leave

215.44 (163.38)

In a normal week, how many days do you work?

4.66 (1.25)

In a normal week, how many hours a day do you work?

7.25 (2.16)

In the last month, how many days did you miss work

because of health problems?

1.63 (5.11)

In the last month, how many days did you have to leave

your usual tasks halfway through or not do them

because of health problems?

11.86 (13.89)

On a scale of 0 to 100, how much work did you do?

63.50 (35.86)

In the last month, how many days did you reduce the

quality of your tasks or were less careful because of

health problems?

13.81 (19.12)

On a scale of 0 to 100, how was the quality of your

work?

71.94 (25.64)

SD: Standard Deviation

The bivariate analysis showed a correlation between the number of symptoms and visits to the family

physician of the public health system (Pearson's P 0.242, p-value: 0.015), and the days missed from

work due to health problems (Pearson's P 0.454, p-value: 0.020). There was no significant bivariate

relationship between the number of symptoms and the rest of the variables.

DISCUSSION

This study aims to shed light on the clinical situation and the use of health, social, and legal resources

because of persistent COVID. The results obtained show that SARS-COV-2 infection and the resulting

persistence of symptoms led to a major change in the lives of these individuals and society. This new

syndrome may affect each person differently, so its impact, both on individuals and on the use of

health, social, and legal services will also be different (Michelen et al., 2021).

The sample can be considered representative, being mainly female. This coincides with other studies

(Asadi-Pooya et al., 2021; Pelà et al., 2022). However, the mean age of the participants in our study is

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10 years younger than in other studies (Evans et al., 2022; Munblit et al., 2021; Sigfrid et al., 2021).

Patients in this study experienced an average of 16.47 symptoms, affecting numerous body systems.

The most frequent persistent symptoms are tiredness and fatigue (98%), poor attention and

concentration (89%), and myalgias (85%), coinciding with other studies that analyze this pathology

(Pelà et al., 2022; Sykes et al., 2021). The existing literature suggests that patients with more

persistent symptoms suffer from greater repercussions on physical function and a psychological

burden that causes more emotional distress (Speed et al., 2017; Storm van's Gravesande et al., 2019).

As for the use of health, social, and legal services by the study participants, we find that the use is

slightly higher than that found in other studies (Abdullah et al., 2023; Menges et al., 2021). According

to the work of Menges et al., 36% of the participants underwent a visit to a general practitioner

related to COVID-19. This may be because, in these studies, the analysis is carried out with cohorts of

individuals infected with COVID-19 with a 12-month follow-up, but many do not have the diagnosis

of persistent COVID. On the other hand, the most commonly used service is family medicine. Primary

health care is the gateway to the health system, the level closest to the citizen, and where the main

health problems are managed (Kennedy, Abbott, & Paykel, 2003; Roca et al., 2009; WHO, 1978). It

should be noted that the public health system is mostly used, except in mental health, and specifically

psychology, since this service is underfunded in the public health system (Confederación Salud Mental

España, 2023). On the other hand, one-third of the patients also used private specialized medicine,

and 8% used alternative medicine services, perhaps due to lack of results from the public system or

because of insufficient treatmentevidence, seekingalternate responses or options.

It should be highlighted that over 72% of the participants were temporarily unable to work over the

last year, a figure that coincides with those of previous studies (Rajan et al., 2021; Van Kessel, Olde

Hartman, Lucassen, & Van Jaarsveld, 2022). Participants who are not on temporary work disability

experienced decreases in the quantity and quality of their work as compared to their pre-illness

capacity. This has also been confirmed in prior works (Davis et al., 2021; Westerlind, Palstam,

Sunnerhagen, & Persson, 2021).

This study has its strengths and limitations. The main strength is its novelty, given that few studies

exist on this topic.The main limitations are the cross-sectional design and the fact that we have not

delved into each of the symptoms or their intensity and their relationship with the use of health,

social, and legal resources. Another study limitation is the lack of depth regarding the use of social

resources.This is due to the use of the Client Service Receipt Inventory questionnaire, in which the

items related to the use of social resources are limited to: visits to social workers and legal

consultations. It should also be considered that, at this stage of the relatively recent disease,

healthcare services are the most commonly used by patients suffering from persistent COVID.

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CONCLUSIONS

This study reveals the intense affectation of individuals suffering from persistent COVID, as reflected

in the large number of residual symptoms experienced by the same. Therefore, there is a considerable

increase in the use of public and private health, social, and legal resources. Primary care services are

the most frequently used by these patients, and almost half of the participants were referred to at

least one specialist. There is also an affectation at the work level, as reflected in the temporary work

disabilities and the quantity and quality of work performed.

ETHICAL CONSIDERATIONS

Ethics approval was granted by the Clinical Research Ethics Committee of Aragón (PI21/454). The

procedures carried out complied with the ethical standards of the previously mentioned committee

and with the 1975 Declaration of Helsinki (revised in 2008). All the subjects signed an informed

consent form, and their data were anonymized and will only be used for the study.

DATA AVAILABILITY STATEMENT

Data supporting the findings of this study are available upon reasonable request to the corresponding

author.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

FUNDING

This study was funded by the Instituto de Salud Carlos III, project FIS PI021/01356, and Feder Funds

Another Way to Make Europe. The funding Institution has not been involved at any time in the

development, analysis, and publication of this study.

AUTHORS' CONTRIBUTIONS

Conceptualization: MªM-P, DO; data collection: IB-G, SL-M.; formal analysis: SL-M; original writing-

drafting: DO, IB-G; writing-revising and editing: all authors. All authors have read and accepted the

published version of the manuscript.

ACKNOWLEDGMENTS

We would like to thank the Aragonese Primary Care Research Group (GAIAP, B21_23R), which is part

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of the Department of Innovation, Research, and University at the Government of Aragón (Spain), the

Primary Care Prevention and Health Promotion Network [RedIAPP-Health Institute Carlos III, Spain

(RD16/0007/0001)], the Research Network on Chronicity, Primary Care and Health Promotion

(RICAPPS, RD21/0016/0005) that is part of the Results-Oriented Cooperative Research Networks in

Health (RICORS) (Carlos III Health Institute), and Feder Funds (Another way to make Europe), for their

support in the development of the study.

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