Reducing variation in the quality of long covid care: Lessons from a national quality improvement collaborative and multi-site ethnography

Abstract

Abstract Context Long covid (post covid-19 condition) is a complex condition with diverse manifestations and uncertain prognosis. There is wide variation in how patients are investigated and managed. There have been calls for formal quality standards so as to reduce a so-called “postcode lottery” of care. We aimed to examine the nature of quality in long covid care and reduce unwarranted variation in care provided by long covid services. Methods In a mixed-method study (2021-2023), we ran a quality improvement collaborative across 10 UK sites. We also gathered data on the origins and current context of each clinic, interviewed staff and patients, and observed 12 clinics (52 consultations) and 34 multidisciplinary team (MDT) meetings (230 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles, reducing unwarranted variation) and philosophy of knowledge. Results The collaborative made progress towards standardizing assessment and management in some topics, but much variation remained. Clinics had different histories and path-dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including (in most clinics) a high proportion of patients with comorbidities. Dimensions of quality prioritized by patients related to the service (e.g. accessibility, ease of navigation), and human qualities of staff (e.g. attentiveness, compassion). A key route to quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients). Conclusion Not all variation in long covid services is unwarranted. Largely because long covid’s manifestations are so varied, universal ‘evidence-based’ standards are hard to define and implement. In this complex condition, quality improvement resources may be better spent supporting team-based learning locally than attempting to standardize care across widely differing services. Trial registration NCT05057260, ISRCTN15022307.