Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care

Benthe H König; Cornelia HM van Jaarsveld; Erik WMA Bischoff; Henk J Schers; Peter LBJ Lucassen; Tim C Olde Hartman

doi:10.3399/BJGP.2022.0158

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Necessity of accurate diagnosis of COVID-19 in primary care
Cornelia H. van Jaarsveld

Published on: 22 May 2023
Necessity of accurate diagnosis of COVID-19 in primary care
Ryuichi Ohta

Published on: 07 May 2023

Published on: (22 May 2023)
Page navigation anchor for Necessity of accurate diagnosis of COVID-19 in primary care
Necessity of accurate diagnosis of COVID-19 in primary care
Cornelia H. van Jaarsveld, Epidemiologist, Radboud university medical center, Department of Primary and Community Care, Nijmegen, The Netherlands
We would like to take this opportunity to respond to three statements in the eLetter by Ryuichi Ohta¹ related to our paper.²

1. “…This research clarified that patients not diagnosed but suspected of COVID-19 tend to have persistent fatigue….”
We now realise that referring to ‘suspected COVID-19’ in our paper might be incorrectly chosen. We selected the term ‘suspected COVID-19’ to be transparent that at the very beginning of the pandemic there was no test capacity in the Netherlands and therefore all patients were included in the study based on a clinical diagnosis of COVID-19.³ In primary care, a clinical diagnosis based on specific symptoms is standard practice for many diseases. All participating GPs are part of a large registration network (FaMe-net) and are therefore experienced in registering morbidity reliably. Although misclassification cannot be completely ruled out, we want to emphasize that all included patients were diagnosed with COVID-19 by GPs using standard best practice clinical criteria.

2. “…Considering this study's results, family physicians should diagnose COVID-19 precisely among physically and mentally vulnerable patients not to induce fatigue among them….”
We believe GPs should always diagnose COVID-19 precisely, not only in vulnerable patients. As highlighted above, all patients included in the study were diag...
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We would like to take this opportunity to respond to three statements in the eLetter by Ryuichi Ohta¹ related to our paper.²

1. “…This research clarified that patients not diagnosed but suspected of COVID-19 tend to have persistent fatigue….”
We now realise that referring to ‘suspected COVID-19’ in our paper might be incorrectly chosen. We selected the term ‘suspected COVID-19’ to be transparent that at the very beginning of the pandemic there was no test capacity in the Netherlands and therefore all patients were included in the study based on a clinical diagnosis of COVID-19.³ In primary care, a clinical diagnosis based on specific symptoms is standard practice for many diseases. All participating GPs are part of a large registration network (FaMe-net) and are therefore experienced in registering morbidity reliably. Although misclassification cannot be completely ruled out, we want to emphasize that all included patients were diagnosed with COVID-19 by GPs using standard best practice clinical criteria.

2. “…Considering this study's results, family physicians should diagnose COVID-19 precisely among physically and mentally vulnerable patients not to induce fatigue among them….”
We believe GPs should always diagnose COVID-19 precisely, not only in vulnerable patients. As highlighted above, all patients included in the study were diagnosed by GPs based on specific clinical symptoms according to current best practice.

3. “…To prevent needless fatigue from suspecting COVID-19 infection, family physicians should be trained, and suspect COVID-19 precisely and cautiously based on the evidence….”
Dr Ohta suggests that our study might have induced fatigue. We are not entirely sure whether Dr Ohta proposes that this may occur due to either misdiagnosing COVID-19 or by exposing vulnerable patients to questionnaires. We consider misdiagnosing as improbable because the GPs diagnosed COVID-19 according to standard practice. In addition, we do not believe that asking patients to fill in a questionnaire about chronic fatigue is causing complaints of long-COVID. Although questionnaires do sometimes cause distress, this is always of short duration.^4,5

By Dr Cornelia van Jaarsveld on behalf of B König, E Bischoff, H Schers, P Lucassen & T Olde Hartman.

References
1. Ohta R. Necessity of accurate diagnosis of COVID-19 in primary care. eLetter Br J Gen Pract; Published on: 07 May 2023.
2. Konig BH, van Jaarsveld CH, Bischoff EW, Schers HJ, Lucassen PL, Olde Hartman TC. Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care. Br J Gen Pract 2023;73:e340-e7.
3. Schers H, van Weel C, van Boven K, et al. The COVID-19 Pandemic in Nijmegen, the Netherlands: changes in presented health problems and demand for primary care. Ann Fam Med 2021;19(1):44–7.
4. Takesaka J, Crowley R, Casarett D. What is the risk of distress in palliative care survey research? J Pain Symptom Manage 2004 Dec;28(6):593-8.
5. Ben-Nun P. (Ed.) Respondent Fatigue in: Encyclopedia of Survey Research Methods. (2008) (Vols. 1-0). Sage Publications, Inc.
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Competing Interests: None declared.
Published on: (7 May 2023)
Page navigation anchor for Necessity of accurate diagnosis of COVID-19 in primary care
Necessity of accurate diagnosis of COVID-19 in primary care
Ryuichi Ohta, Family physician, Unnan City Hospital, Japan
I have read, with great surprise, the research titled “Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care.”¹ This research clarified that patients not diagnosed but suspected of COVID-19 tend to have persistent fatigue, one of the typical symptoms of long COVID in clinical courses, four times more frequently than those not suspected of COVID-19. The clarified associated factors to fatigue were frequent GP contact, polypharmacy, and frequent life events, showing that physically and mentally vulnerable patients tend to have fatigue when suspected of COVID-19.

Considering this study's results, family physicians should diagnose COVID-19 precisely among physically and mentally vulnerable patients not to induce fatigue among them. Long COVID is not understood clearly based on the pathophysiology and prognosis.² Mentally vulnerable patients tend to be affected more by medically vague conditions such as Long COVID, causing further mental stress.³ Although the fear of COVID-19 is dispelled, vulnerable patients are informed about possible critical conditions when infected. So, when diagnosed with COVID-19, they may have colossal stress, causing mental imbalance and manifesting the symptoms of fatigue.³ COVID-19 is not a superficial viral infection and has social aspects affecting patients’ mentality. To prevent needless fatigue from suspecting COV...
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I have read, with great surprise, the research titled “Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care.”¹ This research clarified that patients not diagnosed but suspected of COVID-19 tend to have persistent fatigue, one of the typical symptoms of long COVID in clinical courses, four times more frequently than those not suspected of COVID-19. The clarified associated factors to fatigue were frequent GP contact, polypharmacy, and frequent life events, showing that physically and mentally vulnerable patients tend to have fatigue when suspected of COVID-19.

Considering this study's results, family physicians should diagnose COVID-19 precisely among physically and mentally vulnerable patients not to induce fatigue among them. Long COVID is not understood clearly based on the pathophysiology and prognosis.² Mentally vulnerable patients tend to be affected more by medically vague conditions such as Long COVID, causing further mental stress.³ Although the fear of COVID-19 is dispelled, vulnerable patients are informed about possible critical conditions when infected. So, when diagnosed with COVID-19, they may have colossal stress, causing mental imbalance and manifesting the symptoms of fatigue.³ COVID-19 is not a superficial viral infection and has social aspects affecting patients’ mentality. To prevent needless fatigue from suspecting COVID-19 infection, family physicians should be trained, and suspect COVID-19 precisely and cautiously based on the evidence.

References
1. Konig BH, van Jaarsveld CH, Bischoff EW, Schers HJ, Lucassen PL, Olde Hartman TC. Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care. Br J Gen Pract 2023;73: e340-e7.
2. Mizrahi B, Sudry T, Flaks-Manov N, et al. Long covid outcomes at one year after mild SARS-CoV-2 infection: nationwide cohort study. BMJ 2023;380: e072529.
3. Sun Y, Wu Y, Fan S, et al. Comparison of mental health symptoms before and during the covid-19 pandemic: evidence from a systematic review and meta-analysis of 134 cohorts. BMJ 2023;380: e074224.

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Competing Interests: None declared.