BACKGROUND: A recommendation by the World Health Organization (WHO) was issued about the use of chest imaging to monitor pulmonary sequelae following recovery from COVID-19. This qualitative study aimed to explore the perspective of key stakeholders to understand their valuation of the outcome of the proposition, preferences for the modalities of chest imaging, acceptability, feasibility, impact on equity and practical considerations influencing the implementation of using chest imaging. METHODS: A qualitative descriptive design using in-depth interviews approach. Key stakeholders included adult patients who recovered from the acute illness of COVID-19, and providers caring for those patients. The Evidence to Decision (EtD) conceptual framework was used to guide data collection of contextual and practical factors related to monitoring using imaging. Data analysis was based on the framework thematic analysis approach. RESULTS: 33 respondents, including providers and patients, were recruited from 15 different countries. Participants highly valued the ability to monitor progression and resolution of long-term sequelae but recommended the avoidance of overuse of imaging. Their preferences for the imaging modalities were recorded along with pros and cons. Equity concerns were reported across countries (e.g., access to resources) and within countries (e.g., disadvantaged groups lacked access to insurance). Both providers and patients accepted the use of imaging, some patients were concerned about affordability of the test. Facilitators included post- recovery units and protocols. Barriers to feasibility included low number of specialists in some countries, access to imaging tests among elderly living in nursing homes, experience of poor coordination of care, emotional exhaustion, and transportation challenges driving to a monitoring site. CONCLUSION: We were able to demonstrate that there is a high value and acceptability using imaging but there were factors influencing feasibility, equity and some practical considerations associated with implementation. We had a few suggestions to be considered by the expert panel in the formulation of the guideline to facilitate its implementation such as using validated risk score predictive tools for lung complications to recommend the appropriate imaging modality and complementary pulmonary function test.

Czech National Centre for Evidence Based Healthcare and Knowledge Translation Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic

Department of Health Research Methods Evidence and Impact McMaster University 1280 Main Street West Hamilton Canada

Department of Internal Medicine American University of Beirut Beirut Lebanon

Department of Medicine American University of Beirut Riad El Solh P O Box 11 0236 Beirut 1107 2020 Lebanon

Hariri School of Nursing American University of Beirut Beirut Lebanon

Radiation and Health Unit Department of Environment Climate Change and Health World Health Organization Geneva Switzerland

See more in PubMed

Akl EA, Blazic I, Yaacoub S, Frija G, Chou R, Appiah JA, Fatehi M, Flor N, Hitti E, Jafri H, Jin ZY, Kauczor HU, Kawooya M, Kazerooni EA, Ko JP, Mahfouz R, Muglia V, Nyabanda R, Sanchez M, et al. Use of chest imaging in the diagnosis and management of COVID-19: a WHO rapid advice guide. Radiology. 2021;298(2):E63–E69. doi: 10.1148/radiol.2020203173. PubMed DOI PMC

Alexander A, Jiang A, Ferreira C, Zurkiya D. An intelligent future for medical imaging: a market outlook on artificial intelligence for medical imaging. J Am Coll Radiol. 2020;17(1):165–170. doi: 10.1016/j.jacr.2019.07.019. PubMed DOI

Alonso-Coello P, Schunemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD, Group GW. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices 1: Introduction. BMJ. 2016;353:i2016. doi: 10.1136/bmj.i2016. PubMed DOI

Bazdyrev E, Rusina P, Panova M, Novikov F, Grishagin I, Nebolsin V. Lung fibrosis after COVID-19: treatment prospects. Pharmaceuticals (Basel) 2021 doi: 10.3390/ph14080807. PubMed DOI PMC

Czawlytko C, Hossain R, White CS. COVID-19 diagnostic imaging recommendations. Appl Radiol. 2020;49:10–15. doi: 10.37549/AR2646. DOI

Diaz JV, Herridge M, Bertagnolio S, Davis HE, Dua T, Kaushic C, Marshall JC, Del Rosario Perez M, Strub-Wourgaft N, Soriano JB. Towards a universal understanding of post COVID-19 condition. Bull World Health Organ. 2021;99(12):901–903. doi: 10.2471/BLT.21.286249. PubMed DOI PMC

Dicicco-Bloom B, Crabtree BF. The qualitative research interview. Med Educ. 2006;40(4):314–321. doi: 10.1111/j.1365-2929.2006.02418.x. PubMed DOI

Eberst G, Claude F, Laurent L, Meurisse A, Roux-Claude P, Barnig C, Vernerey D, Paget-Bailly S, Bouiller K, Chirouze C, Behr J, Grillet F, Ritter O, Karaer S, Pili-Floury S, Winiszewski H, Samain E, Decavel P, Capellier G, Westeel V. Result of one-year, prospective follow-up of intensive care unit survivors after SARS-CoV-2 pneumonia. Ann Intensive Care. 2022;12(1):23. doi: 10.1186/s13613-022-00997-8. PubMed DOI PMC

eCOVID-19RecMap. COVID19 Recommendations and Gateway to Contextualization. 2021. Retrieved September 24 from https://covid19.recmap.org/.

Ferrari D, Milic J, Tonelli R, Ghinelli F, Meschiari M, Volpi S, Faltoni M, Franceschi G, Iadisernia V, Yaacoub D, Ciusa G, Bacca E, Rogati C, Tutone M, Burastero G, Raimondi A, Menozzi M, Franceschini E, Cuomo G, et al. Machine learning in predicting respiratory failure in patients with COVID-19 pneumonia-challenges, strengths, and opportunities in a global health emergency. PLoS ONE. 2020;15(11):e0239172. doi: 10.1371/journal.pone.0239172. PubMed DOI PMC

Fields BKK, Demirjian NL, Gholamrezanezhad A. Coronavirus Disease 2019 (COVID-19) diagnostic technologies: a country-based retrospective analysis of screening and containment procedures during the first wave of the pandemic. Clin Imaging. 2020;67:219–225. doi: 10.1016/j.clinimag.2020.08.014. PubMed DOI PMC

Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi: 10.1186/1471-2288-13-117. PubMed DOI PMC

Halalau A, Imam Z, Karabon P, Mankuzhy N, Shaheen A, Tu J, Carpenter C. External validation of a clinical risk score to predict hospital admission and in-hospital mortality in COVID-19 patients. Ann Med. 2021;53(1):78–86. doi: 10.1080/07853890.2020.1828616. PubMed DOI PMC

Heen AF, Vandvik PO, Brandt L, Montori VM, Lytvyn L, Guyatt G, Quinlan C, Agoritsas T. A framework for practical issues was developed to inform shared decision-making tools and clinical guidelines. J Clin Epidemiol. 2021;129:104–113. doi: 10.1016/j.jclinepi.2020.10.002. PubMed DOI

Jiang DH, Roy DJ, Gu BJ, Hassett LC, McCoy RG. Postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection: a state-of-the-art review. JACC Basic Transl Sci. 2021;6(9):796–811. doi: 10.1016/j.jacbts.2021.07.002. PubMed DOI PMC

Jiang ZZ, He C, Wang DQ, Shen HL, Sun JL, Gan WN, Lu JY, Liu XT. The role of imaging techniques in management of COVID-19 in China: from diagnosis to monitoring and follow-up. Med Sci Monit. 2020;26:e924582. doi: 10.12659/MSM.924582. PubMed DOI PMC

Larici AR, Cicchetti G, Marano R, Merlino B, Elia L, Calandriello L, Del Ciello A, Farchione A, Savino G, Infante A, Larosa L, Colosimo C, Manfredi R, Natale L. Multimodality imaging of COVID-19 pneumonia: from diagnosis to follow-up. A comprehensive review. Eur J Radiol. 2020;131:109217. doi: 10.1016/j.ejrad.2020.109217. PubMed DOI PMC

Leung T, Chan A, Chan E, Chan V, Chui C, Cowling B, Gao L, Ge M, Hung I, Ipa M. Short-and potential long-term adverse health outcomes of COVID-19: a rapid review. Emerg Microbes Infect. 2020;9(1):2190–2199. doi: 10.1080/22221751.2020.1825914. PubMed DOI PMC

Leung TYM, Chan AYL, Chan EW, Chan VKY, Chui CSL, Cowling BJ, Gao L, Ge MQ, Hung IFN, Ip MSM, Ip P, Lau KK, Lau CS, Lau LKW, Leung WK, Li X, Luo H, Man KKC, Ng VWS, et al. Short- and potential long-term adverse health outcomes of COVID-19: a rapid review. Emerg Microbes Infect. 2020;9(1):2190–2199. doi: 10.1080/22221751.2020.1825914. PubMed DOI PMC

Lewin S, Glenton C. Are we entering a new era for qualitative research? Using qualitative evidence to support guidance and guideline development by the World Health Organization. Int J Equity Health. 2018;17(1):126. doi: 10.1186/s12939-018-0841-x. PubMed DOI PMC

Liang W, Liang H, Ou L, Chen B, Chen A, Li C, Li Y, Guan W, Sang L, Lu J, Xu Y, Chen G, Guo H, Guo J, Chen Z, Zhao Y, Li S, Zhang N, Zhong N, et al. Development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with COVID-19. JAMA Intern Med. 2020;180(8):1081–1089. doi: 10.1001/jamainternmed.2020.2033. PubMed DOI PMC

Mendelson M, Nel J, Blumberg L, Madhi SA, Dryden M, Stevens W, Venter FWD. Long-COVID: an evolving problem with an extensive impact. S Afr Med J. 2020;111(1):10–12. doi: 10.7196/SAMJ.2020.v111i11.15433. PubMed DOI

MQ, P. Qualitative evaluation methods. 1988.

Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, Cook JR, Nordvig AS, Shalev D, Sehrawat TS, Ahluwalia N, Bikdeli B, Dietz D, Der-Nigoghossian C, Liyanage-Don N, Rosner GF, Bernstein EJ, Mohan S, Beckley AA, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601–615. doi: 10.1038/s41591-021-01283-z. PubMed DOI PMC

Nath A, Smith B. Neurological issues during COVID-19: an overview. Neurosci Lett. 2021;742:135533. doi: 10.1016/j.neulet.2020.135533. PubMed DOI PMC

Organization WH. Clinical Management of COVID-19—Interim Guidance. 2020. Retrieved October 27, 2020 from https://www.who.int/publications/i/item/clinical-management-ofcovid-19.

Peng QY, Wang XT, Zhang LN. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med. 2020;46(5):849–850. doi: 10.1007/s00134-020-05996-6. PubMed DOI PMC

Robey RC, Kemp K, Hayton P, Mudawi D, Wang R, Greaves M, Yioe V, Rivera-Ortega P, Avram C, Chaudhuri N. Pulmonary sequelae at 4 months after COVID-19 infection: a single-centre experience of a COVID follow-up service. Adv Ther. 2021;38(8):4505–4519. doi: 10.1007/s12325-021-01833-4. PubMed DOI PMC

Rubin A, Bellamy J. Practitioner’s guide to using research for evidence-based practice. 2012.

Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–340. doi: 10.1002/1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g. PubMed DOI

Shang W, Kang L, Cao G, Wang Y, Gao P, Liu J, Liu M. Percentage of asymptomatic infections among SARS-CoV-2 omicron variant-positive individuals: a systematic review and meta-analysis. Vaccines (Basel) 2022 doi: 10.3390/vaccines10071049. PubMed DOI PMC

Shaw JA, Smit DP, Griffith-Richards S, Koegelenberg CFN. Utility of routine chest radiography in ocular tuberculosis and sarcoidosis. Int J Tuberc Lung Dis. 2018;22(11):1374–1377. doi: 10.5588/ijtld.18.0013. PubMed DOI

Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022;22(4):e102–e107. doi: 10.1016/S1473-3099(21)00703-9. PubMed DOI PMC

Thornton J. Covid-19: the challenge of patient rehabilitation after intensive care. BMJ. 2020;369:m1787. doi: 10.1136/bmj.m1787. PubMed DOI

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–357. doi: 10.1093/intqhc/mzm042. PubMed DOI

Vehar S, Boushra M, Ntiamoah P, Biehl M. Post-acute sequelae of SARS-CoV-2 infection: caring for the ‘long-haulers’. Cleve Clin J Med. 2021;88(5):267–272. doi: 10.3949/ccjm.88a.21010. PubMed DOI

Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: systematic review of the current evidence. Brain Behav Immun. 2020;89:531–542. doi: 10.1016/j.bbi.2020.05.048. PubMed DOI PMC

WHO. Using evidence from qualitative research to develop WHO guidelines. 2014.

WHO. Living guidance for clinical management of COVID-19. 2021. [Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-2].

WHO. WHO Coronavirus (COVID-19) Dashboard: World Health Organization. 2021. [Available from: https://covid19.who.int/.

WHO. Infection prevention and control in the context of coronavirus disease 2019 (COVID-19): a living guideline. In. 2022. https://www.ncbi.nlm.nih.gov/pubmed/35767666. PubMed

WHO. WHO guidelines on the use of chest imaging in COVID-19. 2022. PubMed

Zhao YM, Shang YM, Song WB, Li QQ, Xie H, Xu QF, Jia JL, Li LM, Mao HL, Zhou XM, Luo H, Gao YF, Xu AG. Follow-up study of the pulmonary function and related physiological characteristics of COVID-19 survivors three months after recovery. EClinicalMedicine. 2020;25:100463. doi: 10.1016/j.eclinm.2020.100463. PubMed DOI PMC