Guidelines for Triage of COVID-19 Patients Presenting With Non-Respiratory Symptoms

Importance: Symptom screening for COVID-19 in the community has been limited by the inability to differentiate between COVID-19 and other diseases with similar clinical presentation. Predictive models provide compelling evidence that current practices can be greatly improved by considering predictive values of symptoms across different body systems in clinical decision-making. Objective: This paper describes how patients’ symptoms can be used to differentiate COVID-19 from other diseases with similar clinical presentation at a point of patient triage in the community. Design: This case-control study used data from two sources: a literature review and a symptom survey. The literature review was used to identify symptoms of COVID-19 and their diagnostic values. The survey data was collected to test the accuracy of diagnosing patients based on their symptoms. Settings: Review of 81 published papers identified 7 respiratory, 9 neurological, 4 gastrointestinal, 4 inflammatory, and 5 general symptoms associated with COVID-19 in a variety of settings – ambulatory, hospital, and community. Survey participants were recruited from the general community. Participants: 483 individuals, 18 years and older, were surveyed, between November 2020 and January 2021, about their COVID-19 test results, in the past 30 days, and any associated symptoms. Main Outcome(s) and Measure(s): The diagnostic values of symptoms were measured using the likelihood ratio associated with each symptom. Likelihood ratios were calculated from either the reported sensitivity/specificity of the symptom or the reported prevalence of the symptom in COVID-19 patients. The accuracy of predicting COVID-19 from the reported symptoms was assessed using the Area under the Receiver Operating Curves (AROC). Results: The accuracy of predicting COVID-19 was highest when patients presented with symptoms across different body systems (AROC of 0.74 to 0.81), and lowest when patients presented with only respiratory symptoms (AROC=0.48). Conclusions and Relevance: Triage of patients to COVID-19 clinics can be improved by focusing on predictive values of symptoms across different body systems. Patients presenting with only respiratory symptoms should be triaged based on rapid diagnostic tests. Funding Information: This project was funded by National Cancer Institute contract number 75N91020C00038 to Vibrent Health, Praduman Jain (Principal Investigator). Declaration of Interests: All listed authors and acknowledged individuals were paid by the contract and had no conflicts of interest to declare. Ethics Approval Statement: This study was approved by George Mason University IRB (number 1668273-8). The consent form was provided online, and completion of the survey was taken as consent to participate in the study.