Performance of national COVID-19 'symptom checkers': a comparative case simulation study

Objectives Identifying those individuals requiring medical care is a basic tenet of the pandemic response. Here, we examine the COVID-19 community triage pathways employed by four nations, specifically comparing the safety and efficacy of national online 'symptom checkers' used within the triage pathway. Methods A simulation study was conducted on current, nationwide, patient-led symptom checkers from four countries (Singapore, Japan, USA and UK). 52 cases were simulated to approximate typical COVID-19 presentations (mild, moderate, severe and critical) and COVID-19 mimickers (eg, sepsis and bacterial pneumonia). The same simulations were applied to each of the four country's symptom checkers, and the recommendations to refer on for medical care or to stay home were recorded and compared. Results The symptom checkers from Singapore and Japan advised onward healthcare contact for the majority of simulations (88% and 77%, respectively). The USA and UK symptom checkers triaged 38% and 44% of cases to healthcare contact, respectively. Both the US and UK symptom checkers consistently failed to identify severe COVID-19, bacterial pneumonia and sepsis, triaging such cases to stay home. Conclusion Our results suggest that whilst 'symptom checkers' may be of use to the healthcare COVID-19 response, there is the potential for such patient-led assessment tools to worsen outcomes by delaying appropriate clinical assessment. The key features of the well-performing symptom checkers are discussed.