Table 3 provides a summary of results for the perceptions of stakeholders of the contextual factors, based on the GRADE EtD framework and Heen et al. practical issues.
In the following text, we present a detailed narrative of themes illustrated by selected quotes from participants. In Additional file 5: Appendices 5–10, we provide exemplary quotes from both providers and patients for each theme.
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A.
Monitoring progression is highly valued when chosen wisely and acceptable.
All patients thought if their providers asked them to do chest imaging post-recovery, they would not question its value and they “would do whatever they [providers] wanted” US-Pa01.
Similarly providers perceived imaging post-COVID-19 as highly valuable when there is clinical indication. Mild cases ‘patients don’t routinely need any kind of follow up imaging’.US-P03.
While moderate and severe cases as well as those with underlying chronic diseases such as human immunodeficiency virus (HIV) infection and tuberculosis coinfection, it will be highly valued, as this participant indicated:
India-P13: So it depends on the severity of the disease during the hospitalization, and the condition of the patient on discharge.
Further, COVID-19 patients, particularly those who were hospitalized might end up with potential multi-organ dysfunction, and the stay in the intensive care unit might expose them to various diseases, such as pneumonia. Hence, for many providers monitoring them post-recovery would be an opportunity to screen and intervene on time to avoid further complications. For example, this provider pointed to low-immunity and co-infection and the importance of frequent monitoring on the treatment.
Nigeria- P06: The follow up is major. Some of them have a low immunity and if we do not catch the bacterial infection on time yes, we lost them. I think the follow up is very crucial.
Interestingly, one provider indicated that, given that this is a new disease, monitoring patients post-recovery can help the scientific understanding of the long-term sequelae of the infection and eventually improve the care.
US-P08: mostly to understand the disease more. You see what they have findings on the imaging initially they have been improving. Also mostly to kind of look at long term sequela of the condition. But mostly to understand the disease itself, which is kind of relatively had been new.
On the other hand, a few provider participants cautioned against over-testing. First, it would be unnecessary since it will not add “to the decision making in terms of therapy…[and] you don’t want them to be having unnecessary exposure to radiation with multiples radiographs or multiple CT scans. India-P09.
Further, over-testing might end up detecting indolent findings, which would add to their psychological stress, hence unethical from the perspective of one participant:
Swiss-P02: “I think so, and then you might have a problem that you start to find incidental findings. And then you’re going to have to deal with following up on other things that you might see on the X ray that may not be even real, you know, and that’s another ethical problem. If they don’t need the radiography, you’re exposing them to radiationThis psychological stress to wait yet for other results depleted patients’ tolerance. Who indicated that they “ would be very anxious because… my lung function might be deteriorating, I might have long term sequela. Ethiopia-Pa03.
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B.
Monitoring and follow-up are a reasonable clinical practice.
Among providers, we found that monitoring using imaging to follow-up on the patient’s resolution, or any potential sequelae of the disease was an acceptable practice, in fact it has been already a common practice among almost all participants except for one participant who indicated that due to poor resources in the country, monitoring was never an option.
Cameroon-P11: No monitoring whatsoever … Okay so I would think it’s very important to do radiological follow up on them specially to see how much damage has occurred in their lungs and also to see if some damages are still continuing after discharge. In essence our potentials in treating COVID- 19 does not lay so much emphasis on radiological findings and I understand that this is a limitation of our treatment.
Providers also indicated that since some COVID-19 patients were already accustomed to monitoring for other underlying diseases, such as for dialysis or cardiac matters, adding chest imaging monitoring would be acceptable for them. However, the downside is that often times patients may need to spend longer time for the visit, which can be beyond their ability to tolerate.
Swiss-P02: Well, I have to say if a patient is on dialysis, and they have to come 3 times a week. So, we see them and …we try to do a radiography at the baseline… we do another radiography or a CT or whatever but basically for us we get to see them pretty routinely… I think for the dialysis patients again, for them, it’s a burden because either they must come earlier to go to the radiography before the dialysis, or then go after dialysis and then it delays them going home. And then it complicates the transport.
Patients found monitoring a reasonable process, however the cost of the test would matter.
Africa-Pa02: No because it [test] is very expensive, both CT scan and treatment
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C.
Preferences for each chest imaging modality are driven by indication and the pros and cons of each.
Preferences for the different imaging modalities were mainly voiced by providers. The clinical indication and the pros and cons for each test dictate the type of test to be done.
Chest radiography is the preferred option for the following conditions: mild cases still complaining of chest pain to monitor clearance of the lungs, and for dialysis patients to detect water retention as one nephrologist indicated:
Swiss-P02: I think honestly, for our patients, sometimes the X rays actually helpful. Because sometimes they lose a lot of weight, and we need to know how much water we need to remove from the patient in a dialysis treatment. And occasionally you don’t know how quickly the patient has lost weight with COVID. So, sometimes you do the X Ray with an excuse of COVID, but you’re actually looking to see, are they filling up with water, are they’re going to develop heart failure. So, for us, sometimes there’s another extra added value.
There were a few pros for using X-rays including ‘reducing the radiation from CT [which] is so large that if you do so frequently, it may not be good or ethical’ US-P07. It is available in local clinics as one provider indicated: ‘a lot of family doctors can do X rays. It’s amazing. They have an X ray thing in their clinic in their little office’ USP02. At times the choice of the test is driven by the cost of the test, therefore providers would choose whatever is affordable for patients as this provider indicated: ‘The common is Chest X ray… but in some cases we do high resolution CT because CT is expensive so we do it for only those who can afford it, not for all of them’ US-P06.
The cons are not being sensitive enough and may miss significant pathology.
‘The chest X Ray, it’s not sensitive enough to show you a significant pathology. And so we have seen it with COVID, you know the chest X Ray misses a proportion, like, 40% or something’ US-P07.
Providers gave several indications for choosing chest CT scan. Chest CT scan is very sensitive to ground glass, consolidation, and fluid retention. It is also recommended for patients still depending on oxygen long after discharge. Often, it is used in cases where providers are anticipating persistent interstitial manifestations like non-specific interstitial pneumonia (NSIP). It can identify fibrotic changes and detect additional diseases, if any.
India- P05: as far as the CT scan is concerned, it is basically, it gives you a fuller picture of the chest. I mean, what is happening inside the lungs, right from the trachea to the lung parenchyma. So generally, the mindset for patients out here is better go for a CT scan because, uh, it gives a good resolution.
The cons included higher radiation exposure, lack of accessibility in local clinics and affordability for various populations.
‘If you want a CT, then the patient has to go to a hospital or a private place and then definitely for some of them it involves travel and sometimes it’s even hours of travel’ US-P02.
The nursing and pregnant women population was of concern for radiologists, as extra precautions are needed to avoid any harm when doing the imaging.
South Africa- P16: So, high radiation risk or high radiation dose to the breasts. And reasonably achievable. So, we try to take it down to the minimum.
Finally, for the lung ultrasound, it is the preferred option to assess peripheral consolidation. It is considered an easy modality test as it is portable, accessible in local clinics, and affordable.
US-P08: … We’ve been relying a lot on it and they’re criteria to follow with the ultrasound. It’s a very easy modality. Yes, we’re using it. And now it’s like, you have those small portable ones. It’s very easy to clean it from room after room, way better than cleaning the whole chest X Ray machine.
The potential for missing central consolidation and significant pathology were cited as the major cons.
‘I mean, scanned by ultrasound, we are only able to see the peripheral one third, which are involved in COVID, but it is not only the peripheral. So central areas, we are not able to visualize using ultrasound’ US-P05.
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D.
Equity concerns across countries and within countries.
The availability of resources and health insurance coverage across and within countries impacted equity. Access to resources varied between developed such as USA and developing countries such as African countries.
One provider from the USA said:
US-P08: We have 2 big centers. CT scan is available very widely. Any issues that need any further care, again, we have video system, so if they need further evaluation, they go to their closest hospital, they get stabilized and they get transferred to one of the biggest centers, which is not too far. And either they get transferred by ground, or they’re sick, they get transferred by air, which is really fast, like talking 10 to 15 minutes by helicopter or a plane. So, the CT scan is widely available if it needs, like, a little bit of more advanced things the biggest centers, definitely, the patients get referred to them, but mostly when they get sick and need admission. For outpatient, like, imaging, scans, pulmonary function test, ultrasounds, these things are very widely available.
Compared with what providers in Africa said:
Cameroon-P11: Okay so I would think it’s very important to do radiological follow up…Most of our district health facilities will not have radiology equipment. So normally we would just do auscultations, and manage them as such, and when they go, we do not follow up.
Ethiopia-P07: We have only one CT scan room, so we don’t want to contaminate that. We have a lot of patients, so we only order chest radiography using a machine which is dedicated for that purpose. So definitely if you ask the people to take CT scan for all those who have COVID, it will definitely it would put a burden to the imaging service we have and also to the health professionals, and they think that they can also have COVID-19.
One patient said when the cost of the test is fully covered, everyone would comply.
Czech-Pa06: it’s covered by the health insurance. Okay. So everyone is covered, everybody in the Czech Republic
But when there is no insurance coverage, then patients would more likely opt out.
Pakistan-Pa04: I am a teacher, so my insurance company is taking care of my entire cost of stay in hospital and all expenses…Not the case for everyone… We are a third world country. For example, Remdesivir many cannot afford it. CT scan is slightly expensive. 75% will not be able to afford those expenses.
Other factors impacting equity include the quality chasm between public and private within a country. Often, the non-insured have to rely on public services, which are typically described as crowded, under-resourced, and generally of poorer quality compared to private ones. Similarly, patients living in urban areas have better accessibility to services as compared to patients living in rural areas.
India- P09: So, CT scan facilities are most of the time available in, at least 2 or 3 cities like ours. Public sector it is a few. It is difficult to access. In private sectors, there are lots of CT scans, but again, the out of expenditure really goes high.
India- P05: Yeah, that can be a problem because the means of travel are, you know, buses and trains in our country for traveling from one area to another and areas who have radiological imaging modalities are mostly located in urban areas and suburban areas.
Finally, non-COVID patients were perceived to be at disadvantage during the pandemic. Despite their needs for follow-up, many were either avoiding health care institutions (out of fear of getting the disease) or were being deferred by their providers to avoid exposing them to the infection. In either case, their follow-up care was being jeopardized by the pandemic.
India-P09: Yeah, so definitely COVID patients are still able to access healthcare in an appropriate period. And it is most unfortunate, those patients who have non-COVID illness, they are much more neglected, uh, because of this whole crisis.
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E.
Barriers and facilitators for feasibility.
Providers reported three facilitators of feasibility. Having a post-recovery COVID-19 unit with protocols was the main lever for providers to act. A provider from Ethiopia said:
‘We have a clinic, which is, uh, you know, we have a head nurse. We have a few. 6 to 7 nurses and because we have limited number of nurses, this group of nurses, half of the time they spend it with the chest team… When they come to the clinic, and we see like, 45 to 50 patients and that divided to like on average 5 residents, 1 fellow and 1 senior. We have to go through each CT scan of each patient’ Ethiopia-P07.
Second, many health centers had already established monitoring systems for other diseases, e.g., kidney disease requiring dialysis. Having the infrastructure already in place made it easier for them to build on it by adding the monitoring process for COVID-19.
‘It will actually be going to be easily integrated because a lot of these patients [oncology patients] they end up getting CT scans and, you know, pet scans routinely. Yeah, because as part of their, you know, follow up and as part of their staging, so I don’t think it will be a problem at all… What we can do, and we’ve been doing that is to try and combine these tests together so that if they have 1 appointment, they can get the rest of it together’ Jordan- P04.
The third facilitating factor was the ability to scale up team efforts. Dedicated teams were able to provide optimal services despite the multiple challenges as illustrated in this quote:
India-P05: Daily, we are able to see around 75 to 100 patients…what we have done in our Institute, that we have a hand, picked a few consultants from my department myself included. So, every other day, and, I mean, every alternate day, we are having emergency duties. So we are having dedicated duties for reporting COVID patients, on CT scan and we do it, uh, every alternate day…I mean, it has increased the burden for sure. But then we are doing it.
But the reported challenges were numerous too.
Most providers from low- and middle-income countries indicated that their human and non-human resources were limited. They did not have enough specialists in the country to do the monitoring, including pulmonologists and radiologists.
‘The lack of specialists to follow these patients. I mean, South Africa is a country of 65M people, and we’ve got 70 pulmonologists’ South Africa-P14.
For both developing and developed countries, the number of support staff available to do the tracing did not commensurate with the need, given the large number of patients.
I think the biggest challenge, obviously there’s a huge number of patients. It is overwhelming like, we’ve created a small group of doctors to, like, call patients and tell them they’re COVID positive and discuss the results. But eventually we were overwhelmed because there just so many positive patients. And so the solution was to then just say, well, you should talk to your ordering provider, your primary provider. The hard part there is as much as everyone is trying to keep up with, things changed so quickly with COVID recommendations, that primary care providers who are giving the right advice 6 weeks ago are no longer giving you the right advice US-P03.
The back log in imaging appointments due to limited number of equipment (e.g., CT scan) challenged the feasibility in developing countries.
‘Yeah, we have a back log. We have a lot of back logs [radiology tests]. Even for admitted patients, it is difficult sometimes’ Ethiopia-P11
Some providers indicated that for elderly population, especially those living in nursing homes, access to imaging would be a challenge due to imposed COVID-19 restrictions.
US-P03: The patient population, that’s a little harder to get imaging on actually patients who go to, like, nursing homes. Because many skilled nursing facilities, they don’t have radiology services there and the ability to get the patient with medical transport from the skilled nursing facility to wherever the radiology is in back or the doctor’s appointment, or whatever, that too is also actually very difficult. So I think that population, that group where they have both mobility and transportation issues is a big one.
Patients reported different feasibility challenges.
One patient who was a severe case indicated that he was extremely deconditioned after discharge. If it was not for the rehabilitation, he would not be able to do any further testing.
US-Pa01: I had to be lying in bed for 3 weeks. So after that, I literally could not stand up. I wasn’t able to sort of get out of the bed into a wheelchair to go to the bathroom for a week. We’re talking about a severe case.
Coordination between health care providers was lacking. For example, one patient reported receiving phone calls from the primary care provider, from their pulmonologist and another from the health center, related to the same issue.
Ethiopia-Pa03: Yeah, I think so. From my side, I was communicating with the social worker from the hospital because I was a staff there, so they call me, and they put me in contact with the psych department…. Things are very decentralized so a lot of guys might call them. The follow up is not organized so this might cause people to avoid seeking health care.
For some, it was too much to bear, too many calls, too many follow-ups.
Swiss-P02: I think they get frustrated because they’re being phoned by a lot of different people. There’s quite a lot of phone calls also by people from the community checking on them and the officials checking that they’re at home and not outside when they should be at home, you know, these things. So I think they get a lot of phone calls. And I know for some of them, it’s definitely quite burdensome yeah, yeah.
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