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The COVID-19 Research Agenda :
Translating Imprecision in Diagnostic and Therapeutic Information Into Clinical Decisions
By Kelly M . Pyrek
The COVID-19 pandemic has triggered a tidal wave of information , and coupled with open-access , immediate repositories of data , this abundance of evidence is overwhelming clinicians who are struggling to translate this critical mass into meaningful and effective patient care .
As Metlay and Armstrong ( 2021 ) acknowledge , “ Among the many extraordinary aspects of the coronavirus disease 2019 ( COVID-19 ) pandemic , the rapidity with which new scientific information has been shared and incorporated into clinical decision making is almost unprecedented . Undoubtedly , rapid incorporation of new scientific information into preventive and therapeutic strategies has been critical in minimizing the morbidity and mortality of this illness . At the same time , the rapid spread of new data has created the potential for premature implementation of new evidence to have widespread negative effects on decisions at the individual patient and health system levels . At the core of this dilemma is an understanding of how much certainty we require for new information to be adopted and change practice .” The researchers add , “ Uncertainty in medicine is a fact of life .”
A group of leading experts in healthcare epidemiology and infectious diseases is hoping to change that with the publication of a new research agenda that defines the critical areas of study to inform clinical practice , policy , and prevention strategies for COVID-19 and future pandemics .
The “ COVID-19 Research Agenda for Healthcare Epidemiology ,” published in January by the Society for Healthcare Epidemiology of America ( SHEA ), identifies the gaps in the understanding of the epidemiology , transmission , and individual as well as public health consequences of viral diseases that were revealed through some of the worst phases of the COVID-19 pandemic .
“ The emergence and rapid world-wide spread of severe acute respiratory syndrome coronavirus 2 ( SARS-CoV-2 ) has led to unprecedented loss of life and socio-economic disruption . The scientific community has risen to this challenge and published an enormous body of work over the past year informing our response to the pandemic and leading to evolving guidelines for treatment , testing , and prevention ,” says Lona Mody , MD , an author of the research agenda . “ Looking to the future , the community still has much to learn . We must be intentional with our approach to improve how we prevent and treat COVID-19 and other viral illnesses .”
Translating imprecision in diagnostic and therapeutic information into clinical decisions requires “ deliberative review and consensus building ,” according to Metlay and Armstrong ( 2021 ), who add that end users of this information “ need to have a framework for evaluating the quality of the information and the relevance of the results to everyday clinical decision-making .”
In their piece , the researchers sought to illustrate how one could use available strategies to evaluate new information as it emerges and incorporate evidence into clinical decisions at the individual and hospital levels . For example , they tackle the common issue of whether clinicians should wear an N95 mask to provide better protection than a regular surgical mask from COVID-19 when conducting rounds . As Metlay and Armstrong ( 2021 ) note , “ Although clear evidence shows that various infection control procedures , including hand hygiene and use of gowns and face masks , are highly effective at reducing nosocomial transmission of a range of pathogens , further details about these procedures are largely not driven by high-grade evidence . For example , a cluster randomized trial from before COVID-19 of N95 respiratory masks versus surgical masks worn during the care of patients with respiratory illnesses during successive respiratory illness seasons did not detect a significant difference in the frequency of laboratory-confirmed influenza among healthcare workers . Yet , an early assumption of the COVID-19 pandemic was that N95 masks provided significantly more protection than surgical masks , with the understanding that absolute risk for transmission likely varied significantly by other factors , including proximity to the patient , whether the patient was also wearing a mask , and whether the patient was having an invasive and / or aerosol-generating procedure . The issue was further complicated by the national shortage of N95 masks , with the immediate consequence that use of N95 masks during all patient interactions would not be sustainable .”
They explain that in this setting , “ infection control leaders and hospital administrators needed to make policy decisions to balance the availability of N95 masks with the available evidence regarding effectiveness — a situation in which a different perspective of the decision maker ( hospital administrator vs . individual healthcare worker ) would likely lead to a different set of decisions . Indeed , guidance from the Centers for Disease Control and Prevention during this time explicitly noted that N95 mask use could be limited in non – aerosol-generating settings if N95 supply was limited . The mixing of supply issues with clinical decisions , a form of rationing , feels uncomfortable to many . A systematic review and meta-analysis reported that N95 masks were statistically more likely than surgical masks to reduce risk for COVID-19 among healthcare workers , further highlighting this tension . In fact , the level of evidence supporting that conclusion was weak . No studies directly compared the effectiveness of the two types of masks , and only one study of N95 masks was of patients with COVID-19 . This study compared outcomes across units in a single hospital ; the high degree of protection attributed to N95 masks was largely the result of an outbreak on a non-N95 unit attributed to a single patient . Yet , such data continue to fuel concerns that healthcare worker risk is unacceptably high in the absence of N95 masks for all patient-care activities in the era of COVID-19 .”