What is the long-term impact of COVID-19 on the Health-Related Quality of Life of individuals with mild symptoms (or non-hospitalised): A rapid review
Authors: Spencer Llinos Haf , Hendry Annie , Makanjuola Abraham , Davies Jacob , Pisavadia Kalpa , Hughes Dyfrig , Fitzsimmons Deb , Wilkinson Clare , Edwards Rhiannon Tudor , Lewis Ruth , Cooper Alison , Edwards Adrian 
Published: September 2022

AbstractThe COVID-19 morbidities model has been widely used since 2020 to support Test and Trace and assess the cost-effectiveness of the COVID-19 vaccination programme. The current iteration of the Long COVID model covers several morbidities associated with COVID-19, which are essential to plan for elective care in the future and identify which services to prioritise. However, there are uncertainties in the model around the long-term health-related quality of life (HRQoL) impact of COVID-19, which is primarily based on data for severe COVID disease or hospitalised patients at present. The COVID-19 morbidities model requires updating to address gaps and reflect the latest HRQoL evidence.The aim of this rapid review was to provide updated HRQoL evidence for the COVID-19 morbidities model to better support decision-making in relation to COVID-19 policy.Thirteen primary studies were identified. People who had an initial mild COVID-19 illness or were not treated in hospital can have a decreased HRQoL post-COVID. However, the extent, severity, and duration of this is not consistent. The evidence on the long-term impact of a mild COVID-19 infection on HRQoL is uncertain.Implications for policy and practice include:An initial mild COVID-19 illness can lead to a reduction in HRQoL and impaired mental health, but there is evidence indicating that patients can show significant recovery up to normal levels after one year.Employers should be aware that employees may have prolonged experiences of impaired mental health, including anxiety, depression, and fatigue, following COVID-19 disease, even if their initial disease was mild (not hospitalised).Public health agencies should make patients with mild COVID-19 disease aware of the potential for ongoing symptoms and ways to mitigate and manage them through raised awareness and education.Health Boards should review their provision of long-COVID services in relation to the extent of impacts identified.Better quality studies that report longitudinal follow-up data on HRQoL for a representative cohort of patients who have had mild COVID-19 are required.Funding statementThe Bangor Institute for Health and Medical Research, Bangor University was funded for this work by the Wales Covid-19 Evidence Centre, itself funded by Health & Care Research Wales on behalf of Welsh Government.Rapid Review DetailsReview conducted byBangor Institute for Health and Medical Research Rapid Review TeamReview TeamDr Llinos Haf Spencer, l.spencer@bangor.ac.ukDr Annie Hendry, a.hendry@bangor.ac.ukMr Abraham Makanjuola, a.makanjuola@bangor.ac.ukMr Jacob Davies, j.davies@bangor.ac.ukMiss Kalpa Pisavadia, kalpa.pisavadia@bangor.ac.ukProfessor Dyfrig Hughes, d.a.hughes@bangor.ac.ukProfessor Deb Fitzsimmons, d.fitzsimmons@swansea.ac.ukProfessor Clare Wilkinson, c.wilkinson@bangor.ac.ukProfessor Rhiannon Tudor Edwards, r.t.edwards@bangor.ac.ukReview submitted to the WCEC inJuly 2022Rapid Review report issued by the WCEC inAugust 2022WCEC TeamAdrian Edwards, Ruth Lewis, Alison Cooper and Micaela Gal involved in drafting, Topline Summary, editing etc.This review should be cited asRR00040. Wales COVID-19 Evidence Centre. What is the long-term impact of COVID-19 on the Health-Related Quality of Life of individuals with mild symptoms (or non-hospitalised): A rapid review. July 2022.This report can be downloaded herehttps://healthandcareresearchwales.org/wales-covid-19-evidence-centre-report-libraryDisclaimerThe views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest.TOPLINE SUMMARYWhat is a Rapid Review?Our rapid reviews use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting rapid reviews, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1-2 months, depending on the breadth and complexity of the research topic/ question(s), extent of the evidence base, and type of analysis required for synthesis.Who is this summary for?The Department of Health and Social Care (DHSC), who have previously created a COVID-19 morbidities model to support the COVID-19 pandemic response. It will also inform Welsh Government policy through work conducted by the Technical Advisory Cell.Background / Aim of Rapid ReviewThe COVID-19 morbidities model has been widely used since 2020 to support Test and Trace and assess the cost-effectiveness of the COVID-19 vaccination programme. The current iteration of the Long COVID model covers several morbidities associated with COVID-19, which are essential to plan for elective care in the future and identify which services to prioritise. However, there are uncertainties in the model around the long-term health-related quality of life (HRQoL) impact of COVID-19, which is primarily based on data for severe COVID disease or hospitalised patients at present. The COVID-19 morbidities model requires updating to address gaps and reflect the latest HRQoL evidence.The aim of this Rapid Review was to provide updated HRQoL evidence for the COVID-19 morbidities model to better support decision-making in relation to COVID-19 policy. The latest edition of the model was published by the DHSC team in December 2020.The review focused on studies reporting on the long-term impact on HRQoL of patients who had experienced mild symptoms or were not treated in hospital. Inclusion was limited to studies that used validated HRQoL measures, which can be mapped onto EuroQol Quality of Life Measure – 5 dimensions (EQ-5D) and conducted in OECD countries. Two existing systematic reviews were used to identify relevant primary studies published before January 2021, with new searches focusing on the period between January 2021 to June 2022.Key FindingsThirteen primary studies were identified.Extent of the evidence baseMost studies (n=8) were cross-sectional surveys or reported on HRQoL outcomes at a single time point post-COVID (n=2). Only three studies (one of which was a case report) provided longitudinal follow-up data, which included changes from baseline or reported data at multiple time points.Only two studies reported on HRQoL beyond six months follow-up: One study reported data at three months, six months, and twelve months follow-up and one study measured outcomes at six to eleven months. Five studies measured HRQoL at three months post COVID-19, one at four months, and one at five months. Three studies reported data at two months or less post COVID-19.Two studies (one was a case report) focused solely on patients with mild infection, whilst the remaining eleven studies also included patients with moderate or severe/critical COVID-19 illness. Three studies included participants categorised as non-hospitalised or hospitalised patients. twelve studies recruited patients attending outpatients or health care settings; one study recruited a general Swedish population who had a previous COVID-19 infection.The studies were conducted in Turkey (n=2), Denmark (n=1), Sweden (n=1), USA (n=2), Chile (n=1), Ukraine (n=1), Mexico (n=1), Austria (n=2), and The Netherlands (n=2). No UK-based studies were identified.Recency of the evidence baseThree studies published in 2022 were conducted in 2021 (Akova & Gedikli, 2022; Bileviciute-Ljungar et al., 2022; Tanriverdi et al., 2022).Summary of resultsPeople who had an initial mild COVID-19 illness or were not treated in hospital can have a decreased HRQoL post-COVID. However, the extent, severity, and duration of this is not consistent.Best evidence availableHan et al., (2022) recruited outpatients who had mild initial COVID-19 disease and measured HRQoL at six to eleven months follow-up; 436/2092 (21%) outpatients responded to the survey. The findings indicated that the burden of persistent symptoms was significantly associated with poorer long-term health status, poorer quality of life, and psychological distress.Siegerink et al., (2021) measured HRQoL at three months, six months, and twelve months follow-up, and recruited patients presenting at hospital with COVID-19, a proportion of whom were not hospitalised. At three months follow-up, 22% (n=9) of the non-hospitalised group reported abnormal Hospital Anxiety and Depression Scale (HADS) scores (cut-off at 16). After six months, this decreased to 16% (for n=4), and 14.8% at twelve months (n=4).Labarca et al., (2021) reported a change from baseline in percentage satisfaction with HRQoL. They found 50% of the (n=18) ‘mild’ (non-hospitalised) COVID-19 patients reported an individual change in HRQoL, categorised as a change of ≥ 10% on a Visual Analogue Scale (VAS) at four months follow-up.Policy ImplicationsAn initial mild COVID-19 illness can lead to a reduction in HRQoL and impaired mental health, but there is evidence indicating that patients can show significant recovery up to normal levels after one year.Employers should be aware that employees may have prolonged experiences of impaired mental health, including anxiety, depression, and fatigue, following COVID-19 disease, even if their initial disease was ‘mild’ (not hospitalised).Public health agencies should make patients with mild COVID-19 disease aware of the potential for ongoing symptoms and ways to mitigate and manage them through raised awareness and education.Health Boards should review their provision of long-COVID services in relation to the extent of impacts identified.Better quality studies that report longitudinal follow-up data on HRQoL for a representative cohort of patients who have had mild COVID-19 are required.Strength of EvidenceThe evidence on the long-term impact of a mild COVID-19 infection on HRQoL is uncertain.