The terms “post-COVID-19 syndrome” and “long COVID” have been coined to encompass several symptoms that emerge or persist after acute SARS-CoV-2 infection.1 The prevalence of these symptoms ranges from 10% to 90% of patients,2,3 and they have a sensible impact on the quality of life of COVID-19 survivors.4,5 The pathophysiology of long-COVID is believed to be multifactorial, including the effects of systemic inflammation during the acute infection as well as neuropsychiatric factors related to posttraumatic stress disorder, sharing also features with the postintensive care syndrome.6
Due to the varying and nonspecific nature of these symptoms, standardized measuring tools are necessary for their assessment. A newly developed tool, the COVID-19 Yorkshire Rehabilitation Screening (C19-YRS),7 has been proposed for the evaluation of the nature and impact of post-COVID-19 symptoms. C19-YRS is a scale designed to telephonically evaluate the symptoms and their impact in the quality of life of COVID-19 survivors,7 and is being used in the implementation of screening, rehabilitation, and follow-up programs for these patients.8 Currently, C19-YRS is endorsed by the National Institute for Health and Care Excellence of the United Kingdom.1
The aim of this study is to assess the performance of the C19-YRS tool in a cohort of survivors from the first pandemic wave, as well as to characterize the health status and nature of post-COVID-19 symptoms in these patients.
A cross-sectional study was conducted involving all patients with real-time reverse transcriptase polymerase chain reaction (rRT-PCR)-confirmed SARS-CoV2- infection from March to May 2020 in our health care area (Lucus Augusti University Hospital, Lugo, Northwestern Spain). COVID-19 survivors were reached via the telephone between November 2020 and February 2021, and C19-YRS was administered. Two members of the research team were in charge of calling the patients and registering their answers.
Both former out- and inpatients were included in the study, provided they did not have dementia or resided in long-term care facilities. Patients were asked for their consent at the beginning of the interview both for recording their answers and accessing their electronic medical records (EMR). EMRs were reviewed and preexisting medical conditions as well as hospitalization or intensive care unit (ICU) admission during acute infection were recorded. Additional questions regarding patients’ educational level were asked. The study was authorized by the Lugo-Santiago Research Ethics Committee within an ongoing infectious diseases patient’s registry.
C19-YRS is a three-part telephone survey.7 The first part includes patients’ gender and age, as well as a record of their health care resources use since the acute SARS-CoV-2 infection (either primary or hospital care, including readmissions and their reasons, where applicable). In the second part, a standardized survey including 16 symptom domains is conducted. These domains include breathlessness, voice impairment, swallowing impairment, nutritional status, mobility, fatigue, self-care, usual activities, symptoms related to pain or discomfort, anxiety, depressive symptoms, posttraumatic stress-related symptoms, urinary and fecal continence, cognition, and overall health perception.
A total of 19 questions are asked, some of which inquire about the emergence of symptoms and their severity, graded 0 to 10, while others require the patients to assess the severity of their symptoms, graded 0 to 10, both currently and before the infection. Current and prior occupational status of patients is also investigated in this part. The third part of the survey consists of an open question about problems that remained unaddressed in the interview and a field for clinician comments.
Statistical analysis was conducted using the SPSS 25 package (IBM, Armonk, NY, 2017). Quantitative variables are reported with their mean and standard deviation, while categorical variables are reported with frequencies and percentages. Wilcoxon signed-rank test for paired samples was used to compare scores before and after the infection since they were expected to observe a severely left-skewed, non-Gaussian distribution. Pearson’s chi-squared test or Fisher’s exact test was used in the subgroup analysis of symptom prevalence, after stratification by gender, age group, presence of comorbidities, and hospitalization needs.
During the first pandemic wave, a total of 745 patients tested positive for SARS-CoV-2, 44 (5.9%) of whom died during the acute infection. From the 701 survivors, 17 patients with dementia (2.4%) and 76 nursing home residents (10.8%) were excluded from the study (Fig. 1). Four hundred forty-three of the remaining patients answered the survey (answer rate 63.2%). The two investigators in charge used a total of 28 four-hour-long sessions (14 sessions each) to contact the patients and administer the questionnaire. The survey was conducted after a mean of 299 ± 23 days since the rRT-PCR diagnosis.
Baseline patient characteristics of the 443 patients are summarized in Table 1. The mean age was 54 ± 16 years, 38.4% of patients were male, and 42.9% had some previous medical condition, the most frequent being hypertension (27.8% of patients). Eighty-seven patients (19.6%) needed hospitalization during the acute infection, and 10 (2.3%) needed admission to an ICU.
|n (%)||N = 433|
|Age, years, mean ± SD||54 ± 16|
|Age older than 65 years||120 (27.0%)|
|Sex (male)||170 (38.4%)|
|Any comorbidity||190 (42.9%)|
|Lung chronic disease||50 (11.3%)|
|Heart chronic disease||27 (6.1%)|
|Chronic kidney disease||7 (1.6%)|
|Admission to hospital||87 (19.6%)|
|Admission to an ICU||10 (2.3%)|
|Work status prior the illness|
|Actively working||280 (63.2%)|
|Medical leave||5 (1.1%)|
|Lost job due to the pandemic||1 (0.2%)|
|Current work status prior|
|Actively working||245 (55.3%)|
|Medical leave||29 (6.5%)|
|Lost job due to the pandemic||5 (1.1%)|
|Health care workera||166 (37.5%)|
C19-YRS RESULTS: USE OF HEALTH RESOURCES AND WORK STATUS
Fifty-eight patients (13.1%) had consulted with their primary care provider after COVID-19, while 44 patients (9.9%) needed hospital care, either emergency room services or hospital admission, up to the moment of the interview. Hospital readmission was observed in 9.2% (8/87) of patients with an index hospitalization; of these, 5 cases were due to causes directly related to the infection.
Before COVID-19, 280 patients were actively employed (63.2%), 16 were unemployed (3.6%), and 5 (1.1%) were on a medical leave. From those employed before COVID-19, 10 (3.5%) patients lost their jobs, 4 of them directly due to the pandemic (1.4%). At the time of the survey 245 patients (55.3%) were actively employed, 29 (6.5%) were on a medical leave due to COVID-19 or its consequences, and 21 (4.7%) were unemployed. Thirty-four patients (7.7%) reported current difficulties in performing their usual duties at their jobs.
Results from the survey are shown in Table 2. Two hundred seventy-six (62.3%) patients complained of at least one symptom. The most affected domain was fatigue, reported in 165 (37.2%) versus 63 (14.2%) patients before COVID-19; new-onset fatigue was recorded in 102/380 patients (26.8%). The global fatigue score was significantly worse at the time of the interview (1.85 vs. 0.39, p < 0.001).
|CURRENT PREVALENCE||CURRENT SCORE||PRE-COVID SCORE||p|
|At rest||15 (3.4%)||0.1 ± 0.8||0.1 ± 0.5||0.003|
|On dressing||25 (5.6%)||0.2 ± 1.1||0.09 ± 0.57||<0.001|
|On walking||148 (33.4%)||1.6 ± 2.5||0.41 ± 1.10||<0.001|
|Laryngeal/airway complications||53 (12.0%)||0.6 ± 1.8||NA|
|Voice||19 (4.3%)||0.2 ± 1.2||NA|
|Swallowing||14 (3.2%)||0.1 ± 0.8||NA|
|Nutrition||67 (15.1%)||0.3 ± 1.2||NA|
|Mobility||97 (21.9%)||1.0 ± 2.1||0.4 ± 1.1||<0.001|
|Fatigue||165 (37.2%)||1.8 ± 2.7||0.4 ± 1.1||<0.001|
|Personal care||16 (3.6%)||0.1 ± 0.8||0.1 ± 0.6||<0.001|
|Usual activities||94 (21.2%)||0.9 ± 2.0||0.2 ± 0.9||<0.001|
|Pain/discomfort||111 (25.1%)||1.1 ± 2.0||0.2 ± 0.9||<0.001|
|Short-term memory||96 (21.7%)|
|Cognitive-communication||42 (9.5%)||0.5 ± 1.7||NA|
|Anxiety||131 (29.6%)||1.5 ± 2.6||0.2 ± 0.8||<0.001|
|Depression||111 (25.1%)||1.3 ± 2.5||0.4 ± 1.2||<0.001|
|Unwanted memories||Any||61 (13.8%)||NA|
|Unpleasant dreams||Any||12 (2.7%)||NA|
|Avoid thoughts||Any||32 (7.2%)||NA|
|Thoughts about harming yourself||Any||0 (0.0%)||NA|
Breathlessness walking up a flight of stairs was also frequent with 148 patients (33.4%), reporting it at the time of the survey compared with 72 (16.3%) before the infection, with a new-onset ratio of 20.5% (76/371). A significant worsening in breathlessness while walking was observed (0.41 vs. 1.57; p < 0.001). Breathlessness at rest or while dressing was infrequent after the infection (3.4% and 5.6%, respectively), but scores were worse than before the disease (0.13 vs. 0.06, p = 0.003, and 0.25 vs. 0.09, p < 0.001, respectively).
Anxiety-related symptoms were also frequent: 131 (29.6%) patients reported anxiety at the time of the interview compared with 60 (13.5%) before COVID-19, with a new-onset ratio of 18.5% (71/383) and a significant increase of the anxiety score (1.52 vs. 0.44, p < 0.001). Pain and discomfort were reported by 111 (25.1%) patients compared with 36 (8.1%) before the infection, with a significant worsening of scores (1.07 vs. 0.22, p < 0.001).
Other severe less frequent symptoms were weight loss (15.1%), mobility impairment (21.9%), and posttraumatic stress-related symptoms (13.8% from which 59% were moderate or severe). Impairment of self-care ability (3.6%), swallowing (3.2%), and urinary incontinence (2.7%) were seldom reported, while no patients complained about fecal incontinence.
The relationship between symptoms development and gender, age, presence of previous conditions, and hospitalization was investigated.
Female patients had significantly more pain of new onset (22.0% vs. 8.8%, p < 0.001), airway complaints (15.0% vs. 7.1%, p = 0.012), concentration (20.9% vs. 12.4%, p = 0.022), and short-term memory (25.3% vs. 15.9%, p = 0.020) impairment than males. Women also reported more fatigue than men (26.0% vs. 18.2%; p = 0.059), although the trend was not significant. Male patients presented a higher rate of swallowing difficulties (5.35 vs. 1.8%, p = 0.043). No differences were found in terms of health resource use or hospital readmission.
Patients younger than 65 years reported higher rates of pain and discomfort (20.1% vs. 8.3%, p = 0.003). Elderly patients presented more often weight loss (25.0% vs. 11.5%, p < 0.001), urinary incontinence (7.5% vs. 0.9%, p < 0.001), and short-term memory impairment (29.2% vs. 18.9%, p = 0.020) than their younger counterparts. Older patients also had a higher readmission rate (4.2% vs. 0.9%, p = 0.023) and a higher use of health resources (18.3% vs. 11.1%, p = 0.046).
Fatigue of new onset was rarer in patients with previous medical conditions (27.7% vs. 16.8%, p = 0.007), while they had a higher rate of weight loss (21.6% vs. 10.3%, p = 0.001), urinary incontinence (4.7% vs. 1.2%, p = 0.023), and unpleasant dreams (5.8% vs. 0.4%, p < 0.001) than previously healthy individuals. Comorbid patients had also a higher rate of hospital services consultation (14.7% vs. 6.3%, p = 0.003), primary care consultation (16.8% vs. 10.3%, p = 0.043), and readmission (3.7% vs. 0.4%, p = 0.010).
Finally, patients who had needed hospitalization reported higher rates of breathlessness at walking (28.7% vs. 14.3%, p = 0.001), weight loss (52.9% vs. 5.9%, p < 0.001), urinary incontinence (9.2% vs. 1.1%, p < 0.001), short-term memory impairment (37.9% vs. 17.7%, p < 0.001), and unpleasant dreams (6.9% vs. 1.7%, p = 0.007). This subgroup also needed more consultations with hospital services (28.7% vs. 5.3%, p < 0.001) and primary care (25.3% vs. 10.1%, p < 0.001) than patients with outpatient management.
We present the results of the administration of the C19-YRS questionnaire to the survivors of the first pandemic wave. This telemedicine tool has been proven useful in the detection of emerging and worsening symptoms after the acute infection.8 In our study, two investigators with no previous training in the use of the questionnaire could reach >600 patients and record the answers of 443 in a relatively short time, spending an average of around 10 min per patient. Considering the high cumulated prevalence of SARS-CoV-2, this is an interesting characteristic for a long-COVID screening tool.
This can be particularly important given the high consumption of resources by COVID-19 patients. In our sample, 9.2% of patients who had been hospitalized needed readmission after the acute episode, in line with previous reports showing rates between 5%9 and 10%.10 The C19-YRS also revealed a sizeable use of outpatient services, which outlines the need for planned clinical pathways for these patients, which should stratify their condition and, if necessary, the severity of the problem.11 Also, this tool allows for the profiling of the labor impact of the infection, revealing that 8.9% of workers were on a medical leave 10 months after the infection, and that 3.5% had lost their jobs. These results highlight the impact that the pandemic can have in the medium and long term beyond health and economic losses, specifically on the quality of life and mental health of patients.12
The most reported symptoms were fatigue and dyspnea, akin to what is described in other studies of virtual review of long-COVID symptoms13,14 as well as in the present studies.6 The tool points also to some patient subgroups that might be more severely affected in the long term. Women had more impaired areas of symptoms than men, even when they had fewer pathologies and less request for hospital and ICU admission.
Previous studies have pointed to the female gender as a risk factor for greater involvement after acute SARS-CoV-2 infection,13,15 as well as a worse health perception after any illness.12,16 There are probably social and personal factors that contribute to this beyond biological differences, which should prompt a recalibration of our current approach to health-related quality of life in women. In addition, increasing age and previous medical conditions were linked to a higher use of health care resources; this has been reported in relation to COVID-19,17 but also before the pandemic.18
Overall, this study shows that C19-YRS, already endorsed by health authorities,1 is a promising telemedicine tool that makes it possible to screen and assess large numbers of COVID-19 survivors for long-COVID symptoms, in a relatively fast, resource-sparing way. Although it has the usual pitfalls of a telephone questionnaire, namely, retrospective collection of data with inherent recall bias and difficulty of establishing causal relationships, it has already been validated.19 By using this tool on a considerable sample size with a high response rate, it allows for the detection and quantification of both health and occupational issues. Interestingly, results obtained using the C19-YRS are consistent with other studies reviewing postacute symptoms both remotely13,14 and face-to-face.6 Once patients with problems have been identified, C19-YRS could be used as a tool to assess them during the follow-up.
B.A.G. and R.R.R. designed the study and screened the patients. A.P.L., A.R.Á., and Y.B.B. administered the survey and acquired the data. B.A.G. and Á.M.-L. performed the statistical analysis and conducted the plot elaboration. B.A.G. created the first draft of the article. E.R.L. and Maria J.G.P. participated in the data interpretation and edited the article. B.A.G. wrote the final draft of the article and implemented all the changes suggested by the coauthors. R.R.R. and J.C.S. reviewed and corrected the final article.
This study was approved by the Santiago-Lugo Clinical Research Ethics Committee.
An anonymized copy of the data set used in this study can be obtained through the corresponding author.
No competing financial interests exist.
No funding was received for this article.
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