Changes in Prescribing of Psychotropic Medication in Primary Care through the COVID-19 Pandemic in England: A National Level Prospective Survey (preprint)

BackgroundThe COVID-19 pandemic globally impacted healthcare provision. Prescribing changes of common medications can be used as a marker for new diagnoses.AimTo describe how psychotropic prescribing in England was affected by the COVID-19 pandemic.MethodsPrimary Care Prescribing data for different classes of drug from March 2017 - February 2022 were considered. To capture the impact during periods of restricted access to health services for new diagnoses/existing conditions, repeat prescriptions/episodic prescribing were included with account taken of historical trend.The pre-pandemic prescriptions issued each month from March 2017 - February 2020 were linearly extrapolated forward to give an expected annual growth (EAG). The monthly average expected prescriptions for the pandemic period (March 2020–February 2022) were compared with this.ResultsPhysical health medications had lower monthly prescriptions during the pandemic with antibiotics down -12.2%(EAG -1.4%). Most repeat prescriptions were for bronchodilators -1.8%(EAG 0%), hypertension and heart failure -1.3%(EAG 1%), and lipid regulating drugs at -0.1%(EAG 2.3%). Mental Health monthly prescribing increased with hypnotics/anxiolytics by 0.6%(EAG -2.4%), antipsychotics by 0.5%(EAG 2.7%) and antidepressants by 0.3% (EAG 4.9%) The three main antidepressant were: Sertraline grew by 21% so its share of total anti-depressants increased from 22.7% to 24.6% (+8%), Mirtazapine grew by 16% so share increased from 13.0% to 13.6% (+5%), Venlafaxine grew by 11% so share stayed at 6.3%(0%).ConclusionThe increase in anxiolytic/hypnotic prescribing above trend links to pandemic effects on anxiety/worry. The slight increase in antipsychotic prescribing may relate to antipsychotic use in care homes.

Status loss due to COVID-19, traditional masculinity, and the prediction of suicidal ideation and recent suicide attempts (preprint)

Background: The COVID-19 pandemic is causing extensive job loss leading to a loss of social status in many men. Endorsement of traditional masculinity ideology may render some men particularly sensitive to status loss and thereby to an increased risk for suicidality. Methods: In this anonymous online survey conducted in German-speaking European countries, 490 men completed questionnaires regarding loss of social status due to the pandemic, suicidal ideation and past-month suicide attempt. Furthermore, prototypical and male-typical externalizing depression symptoms, self-identified masculine gender orientation, endorsement of traditional masculinity, and gender role conflict were measured. Results: Out of a total of 490 men, 14.7% of men reported experiencing a status loss due to the pandemic. These men were more than twice as likely to report suicidal ideation during the past two weeks, and more than four times as likely to have attempted suicide in the past month than men not reporting a status loss. Depression symptoms, self-identified masculine gender orientation, endorsement of traditional masculinity, but not gender role conflict were positively associated with status loss. Suicidal ideation and suicide attempt were associated with prototypical and male-typical externalizing depression symptoms, but not masculinity- related constructs. Conclusion: Status loss emerges as risk factor for suicide and is associated with depression symptoms, higher masculine gender orientation and endorsement of traditional masculinity. Men with high levels of traditional masculinity and status loss due to the pandemic are at increased risk for suicide.

Analysis of continuous glucose tracking data in people with Type 1 Diabetes (T1DM) after Covid-19 Vaccination reveals unexpected link between immune and metabolic response, augmented by adjunctive oral medication (preprint)

Introduction: The COVID-19 vaccination programme is under way. Anecdotal evidence is increasing that some people with Type 1 Diabetes Mellitus (T1DM) experience temporary instability of blood glucose (BG) levels post-vaccination which normally settles within 2-3 days. We report an analysis of BG profiles of 20 individuals before and after vaccination. Methods We examined the BG profile of 20 consecutive adults (18 years of age or more) with T1DM using the FreeStyle® Libre flash glucose monitor in the period immediately before and after COVID-19 vaccination. The primary outcome measure was percentage(%) BG readings in the designated target range 3.9-10mmmol/L as reported on the LibreView portal for 7 days prior to the vaccination (week -1) and the 7 days after the vaccination (week +1). Results There was a significant decrease in the %BG on target following the COVID-vaccination for the 7 days following vaccination (mean 45.2% ±se 4.2%) vs pre-COVID-19 vaccination (mean 52.6% ±se 4.5%). This was mirrored by an increase in the proportion of readings in other BG categories 10.1-13.9%/ ≥14%. There was no significant change in BG variability in the 7days post COVID-19 vaccination. This change in BG proportion on target in the week following vaccination was most pronounced for people taking Metformin/Dapagliflozin+basal bolus insulin (-23%) vs no oral hypoglycaemic agents (-4%), and median age <53 vs ≥53 years (greater reduction in %BG in target for older individuals (-18% vs -9%)). Conclusion In T1DM, we have shown that COVID-19 vaccination can cause temporary perturbation of BG, with this effect more pronounced in patients talking oral hypoglycaemic medication plus insulin, and in older individuals. This may have consequences for patients with T2DM who are currently not supported by flash glucose monitoring.

An Analysis of the Perspective of Last Year Medical Students in Training Allocated to Manage COVID-19 Hospital Patients in Mexico (preprint)

BackgroundIn order to address the COVID-19 pandemic, health systems have used all their resources, including health care workers in training. Knowing the insights of these workers is of the utmost importance to generate adequate educative/political /administrative strategies. Methods An anonymous cross-sectional online survey was made by the General Directorate of Quality and Health Education in Mexico, in a convenience sample of 6,020 participants who belong to personnel in training for the health area, which included practitioners and professional technologists, undergraduate doctors, nursing, and residents in several specialties.ResultsDifferent positive and negative feelings were identified by the health workers who participated in facing this health emergency; emphasizing elements such as the need for Personal Protection Equipment (PPE) that, when deficient or lacking, generate concerns that raise questions about the medical/epidemiological attention to the pandemic. Based on an analysis of feelings, 8 main feelings were identified, which by frequency of appearing were: distrust(24.83%), fear(21.97%), sadness(12.45%), anticipation(11.65%), anger(10.71%), disgust(9.69%), joy(4.97%) and surprise(3.72%) which influence health workers in training and their wrok performance day to day.Concerning their positive and negative evaluation of their experience facing this health emergency, 13.83% of participants had a positive perception about participating in this kind of health emergency to support the country, 49.94% showed a negative evaluation, and 36.23% kept a neutral evaluation about their participation.ConclusionsThe health workers in training in Mexico gave a negative evaluation of the management of the health emergency. Distrust as a response to the absence of timely information from the education/health institutions, as well as concern about lack of personal protection equipment/inputs, are the main conflicts reported. We must establish a credible globally relevant continuity plan for the education of health care personnel in training, facing emergencies and disasters, so that next time we are properly prepared.

How fast should social restrictions be eased in England as COVID-19 vaccinations are rolled out? (preprint)

Vaccination against the COVID-19 virus began in December 2020 in the UK and is now running at 5% population/week. High Levels of social restrictions were implemented for the third time in January 2021 to control the second wave and resulting increases in hospitalisations and deaths. Easing those restrictions must balance multiple challenging priorities, weighing the risk of more deaths and hospitalisations against damage done to mental health, incomes and standards of living, education outcomes and provision of non-Covid-19 healthcare. Weekly and monthly officially published values in 2020/21 were used to estimate the impact of seasonality and social restrictions on the spread of COVID-19 by age group, on the economy and healthcare services. These factors were combined with the estimated impact of vaccinations and immunity from past infections into a model that retrospectively reflected the actual numbers of reported deaths closely both in 2020 and early 2021. It was applied prospectively to the next 6 months to evaluate the impact of different speeds of easing social restrictions. The results show vaccinations are significantly reducing the number of hospitalisations and deaths. The central estimate is that relative to a rapid easing, the avoided loss of 57,000 life years from a strategy of relatively slow easing over the next 4 months comes at a cost in terms of GDP reduction of around £0.4 million/life-year loss avoided. This is over 10 times higher than the usual limit the NHS uses for spending against Quality Adjusted Life Years (QALYs) saved. Alternative assumptions for key factors affecting give significantly different trade-offs between costs and benefits of different speeds of easing. Disruption of non-Covid-19 Healthcare provision also increases in times of higher levels of social restrictions. In most cases, the results favour a somewhat faster easing of restrictions in England than current policy implies.

Comparing cost of intravenous infusion and subcutaneous biologics in COVID-19 pandemic care pathways -- A brief UK stakeholder survey (preprint)

Objectives: One important group of people at higher risk from the COVID-19 pandemic are those with autoimmune conditions including rheumatoid arthritis/inflammatory bowel disease. To minimise infection risk, many people are now being switched from intravenous to subcutaneous biologics including biosimilars. A key question is how transition costs are viewed by clinicians. Design The survey was designed to understand the comparative economic issues related to the intravenous infusion vs subcutaneous biologic administration routes for infliximab. The survey focused on direct cost drivers/indirect cost drivers. Wider policy implications linked to the pandemic were also explored. Setting/Participants Semi structured telephone interviews were carried out with twenty key stakeholders across the NHS from clinical/pharmacy/commissioning roles. The interviews were undertaken virtually 5thApril-27thApril 2020 and included a semi-structured interview framework with questions across the two administration routes. Results From interview results a simple cost analysis was developed plus a qualitative analysis of reports on wider policy/patient impacts. Key findings included evidence of significant variation in infusion tariffs UK wide, with interviewees reporting that not all actual costs incurred are captured in published tariff costs. A cost analysis showed administration costs 50% that of infusion, with a most patients administering subcutaneous medicines themselves. Other indirect benefits to this route included less pressure on infusion unit waiting times and reduced risk of COVID-19 infection plus reduced patient costs. However, this was to some extent offset by increased pressure on home-care and community/primary care services. Conclusions Switching from infusion to subcutaneous routes is currently being driven by the COVID-19 pandemic in many services. A case for biologics (infusion vs subcutaneous) must be made on accurate real-world economic analysis. In an analysis of direct/indirect costs, excluding medicine acquisition costs, subcutaneous administration appears to be the more cost saving option for many patients even without the benefit of industry funded home-care.

An Analysis of the Perspective of People in Training “Conscripted” to Manage COVID-19 Hospital Patients in Mexico (preprint)

Background: In order to address the COVID-19 pandemic, health systems have used all their resources, including health care workers in training. Knowing the insights of these workers is of the utmost importance to generate adequate educative/political /administrative strategies. Methods An anonymous cross-sectional online survey was made by the General Directorate of Quality and Health Education in Mexico, in a convenience sample of 6,020 participants who belong to personnel in training for the health area, which included practitioners and professional technologists, undergraduate doctors, nursing, and residents in several specialties. Results Different positive and negative feelings were identified by the health workers who participated in facing this health emergency; emphasizing elements such as the need for Personal Protection Equipment (PPE) that, when deficient or lacking, generate concerns that raise questions about the medical/epidemiological attention to the pandemic. Based on an analysis of feelings, 8 main feelings were identified, which by frequency of appearing were: distrust(24.83%), fear(21.97%), sadness(12.45%), anticipation(11.65%), anger(10.71%), disgust(9.69%), joy(4.97%) and surprise(3.72%) which influence health workers in training and their wrok performance day to day. Concerning their positive and negative evaluation of their experience facing this health emergency, 13.83% of participants had a positive perception about participating in this kind of health emergency to support the country, 49.94% showed a negative evaluation, and 36.23% kept a neutral evaluation about their participation. Conclusions The health workers in training in Mexico gave a negative evaluation of the management of the health emergency. Distrust as a response to the absence of timely information from the education/health institutions, as well as concern about lack of personal protection equipment/inputs, are the main conflicts reported. We must establish a credible globally relevant continuity plan for the education of health care personnel in training, facing emergencies and disasters, so that next time we are properly prepared.

Age of people with Type 2 diabetes and the risk of dying following SARS-CoV-2 infection (preprint)

Our analysis as described in this research letter highlights the fact that age outweighs many other factors in people with T2DM in relation to mortality from SARS-CoV-2 virus, once infected. This fact should be taken into account in relation to the vaccination programme against coronavirus-19 in people with T2DM in the UK and elsewhere.

Impact of the UK COVID-19 pandemic on HbA1c testing and its implications for diabetes diagnosis and management (preprint)

Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for diabetes mellitus (DM). Ironically, failure to focus of the wider implications for people with DM and other groups with long-term conditions, may place them at increased risk of poor outcomes from SARS-CoV-2 infection itself, irrespective of the implications for their longer-term health prospects.

A phased approach to unlocking during the COVID-19 pandemic; Lessons from trend analysis (preprint)

With the COVID-19 pandemic leading to radical political control of social behaviour, including restricted movement outsides homes. Can more detailed analysis of the published confirmed local case data from the pandemic in England using infection ratio and comparing local level data provide a deeper understanding of the wider community infection and inform the future unlocking process. The historic daily published 78,842 confirmed cases in England up to 13/4/2020 in each of 149 Upper Tier Local Authority (UTLA) were converted to Average Daily Infection Rate (RADIR), an R-value - the number of further people infected by one infected person after their 5-day incubation and during their 5-day infectious phase, and the associated Rate of Change of Infection Rate ({delta}IR) also calculated. Results compared to look for significant variances between regions. Stepwise regression was carried out to see what local factors could be linked to the difference in local infection rates. The peak of COVID-19 infection has passed. The current RADIR is now below 1. The rate of decline is such that within 14 days it may be below 0.5. There are significant variations in the current RADIR and {delta}IR between the UTLAs, suggesting that the disease locally may be at different stages. Regression analysis across UTLAs found that the only factor that could be related to the fall in RADIR was an increase in the number of confirmed infection/1,000 population. Extrapolation of these results showed that based on assuming a link to increased immunity, unreported community infection may be over 200 times higher than the reported confirmed cases providing evidence that by the end of the second week in April 26% of the population may already have had the disease and so now have increased immunity. Linking these increased estimated infected numbers to recorded deaths indicates a possible mortality rate of 0.14%. Analysis of the current reported local case data using the infectious ratio does provide greater insight into the current levels of community infection and can be used to make better-informed decisions about the future management of restricted social behaviour and movement

COVID-19: Modelling Local Transmission and Morbidity effects to provide an estimate of overall Relative Healthcare Resource Impact by General Practice Granularity (preprint)

Introduction Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the name given to the 2019 novel coronavirus. COVID-19 is the name given to the disease associated with the virus. SARS-CoV-2 is a new strain of coronavirus that has not been previously identified in humans. Methods Two key factors were analysed which when multiplied together would give an estimate of relative demand on healthcare utilisation. These factors were case incidence and case morbidity. GP Practice data was used as this provided the most geographically granular source of published public population data. To analyse case incidence, the latest values for indicators that could be associated with infection transmission rates were collected from the Office of National Statistics (ONS) and Quality Outcome Framework (QOF) sources. These included population density, % age >16 at fulltime work/education, % age over 60, % BME ethnicity, social deprivation as IMD 2019, Location as latitude/longitude, and patient engagement as % self-confident in their own long term condition management. Average case morbidity was calculated by applying the international mortality Odds Ratio to the local population relevant age and disease prevalences and then summing and dividing by the equivalent national figure. To provide a comparative measure of overall healthcare resource impact, individual GP practice impact scores were compared against the median practice. Results The case incidence regression is a dynamic situation with the significance of specific factors moderating over time as the balance between external infection, community transmission and impact of mitigation measures feeds through to the number of cases. It showed that currently Urban, % Working and age >60 were the strongest determinants of case incidence. The local population comorbidity remains unchanged. The range of relative HC impact was wide with 80% of practices falling between 20%-250% of the national median. Once practice population numbers were included it showed that the top 33% of GP practices supporting 45% of the patient population would require 68% of COVID-19 healthcare resources. The model provides useful information about the relative impact of Covid-19 on healthcare workload at GP practice granularity in all parts of England. Conclusion Covid-19 is impacting on the utilisation of health and social care resources across the country. This model provides a method for predicting relative local levels of disease burden based on defined criteria and thereby providing a method for targeting limited (and perhaps soon to be scarce) care resources to optimise national, regional and local responses to the COVID-19 outbreak.