COVID-19 Follow-up Practices Vary Widely Across Europe

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Results of an END-COVID CRC survey of European COVID-19 follow-up programs spotlight the wide variation in these programs’ procedures and clinical design.

European countries vary widely in their management of COVID-19 follow-up. Differences exist regarding use of rehabilitation, telemedicine, and multidisciplinary clinical teams, as well as follow-up programs’ inclusion criteria and use of functional evaluation and imaging. These are among survey findings reported in a research letter in the European Respiratory Journal.

European health care systems face a significant burden from patients with post-COVID-19 syndrome and lung sequelae; a third of patients report impaired quality of life 3 months following COVID-19 diagnosis. However, the research letter authors noted that “the optimal follow-up after severe COVID-19 infection is still unclear,” and that follow-up programs vary widely in the absence of standard operation procedures (SOPs) and research providing clear direction.

To address the lack of information available, a survey on COVID-19 follow-up programs was conducted by the European Respiratory Network for Data sharing on COVID-19 (END-COVID) Clinical Research Collaboration (CRC). The survey, which included 31 questions about general organization of programs, characteristics of follow-up visits, telemedicine availability, and patients’ inclusion criteria, was sent via email to END-COVID academic stakeholders, the European Respiratory Society (ERS) assembly on interstitial lung disease (ILD), and other interested ERS members. A total of 130 centers across 26 countries were included in the final survey results, with responses accepted through September 2021 and only 1 response permitted from each center. The majority of respondents were pulmonologists (90.9%); the majority of centers responding were university hospitals (79.2%).

Overall, the survey found vast differences in management across European countries of post-COVID-19 syndrome with respect to telemedicine availability (0 to 43%), the presence of multidisciplinary teams (0 to 100%), the availability of rehabilitation (0 to 100%), and the timing of a patient’s first follow-up visit (1 to 6 months). The survey results also highlighted widespread heterogeneity across European countries with respect to imaging, functional evaluations, and criteria for inclusion in follow-up programs. The survey also found that COVID-19 follow-up programs at European centers conducted more high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs) than suggested by international guidelines.

More specifically, the survey found that:

  • A dedicated clinical unit managed COVID-19 follow-up programs in two-thirds of the centers, mostly in the pulmonary department.
  • Multidisciplinary teams were integral in more than 80% of follow-up programs and included neurologists (10.8%), cardiologists (15.4%), infectious disease specialists (15.4%), dieticians (27.7%), psychologists/psychiatrists (46.2%), nurses (63.1%), and physiotherapists (84.6%); a general practitioner was only incorporated into 1 program.
  • More than 40% of centers included patients only after hospitalization and more than 50% included both ambulatory patients with persistent symptoms and those previously hospitalized.
  • Persistent post-COVID-19 symptoms (64%), intensive care admission (86%), mechanical ventilation during hospitalization (87%), and the need for oxygen therapy at hospital discharge (89%) represented the most common criteria used by follow-up programs to include patients. Follow-up visits represented an SOP for more than 98% of centers.
  • Telemedicine was available in 30% of the centers, and the most used tools during telemonitoring were PFTs, HRCT scan, blood tests, and quality of life questionnaires.
  • Follow-up timing with patients after hospital discharge ranged from 2 to 13 weeks when telemedicine was employed and 1 to 6 months for face-to-face visits.
  • Face-to-face visits involved checking for dyspnea (94%) and cough (51%) and performing imaging (96%) and functional assessment (79%).
  • With respect to diagnostic techniques employed, less than 40% of centers used chest radiography or HRCT imaging alone, and less than 20% used both. More than 90% of centers used spirometry and measured diffusing capacity of the lung for carbon monoxide, while less than 10% used spirometry alone; and more than 70% routinely used the 6-minute walking test.
  • Approximately two-thirds of centers incorporated an integrated rehabilitation program.
  • Psychological support was offered in nearly two-thirds of centers.

Survey limitations include the lack of information about COVID-19 follow-up programs managed by health care professionals other than pulmonologists, and the exclusion of programs begun after the survey’s conclusion in September 2021. Additionally, most of the responses were from university hospitals in 5 countries, with almost a third of the centers focused on ILD.

Investigators concluded that “The heterogeneity in SOPs across different countries…should be interpreted as a reasonable response to post-COVID-19 syndrome in view of the dissimilar temporal incidence of COVID-19 outbreaks, various epidemiology of SARS-CoV-2 variants, population characteristics and healthcare system structures.” However, added the authors, “In order to include different health systems in the implementation of European interventional trials and to facilitate research on post-COVID-19 syndrome, a homogeneous approach to SOPs could be considered.”

Disclosure: This research was supported by AstraZeneca, Boehringer Ingelheim, Novartis and Roche. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Valenzuela C, Nigro M, Chalmers JD, et al. COVID-19 follow-up programs across Europe: an ERS END-COVID CRC survey. Eur Respir J. Published online July 21, 2022. doi:10.1183/13993003.00923-2022