Trends and associated factors for Covid-19 hospitalisation and fatality risk in 2.3 million adults in England (preprint)

Background The Covid-19 case fatality ratio varies between countries and over time but it is unclear whether variation is explained by the underlying risk in those infected. This study aims to describe the trends and risk factors for admission and mortality rates over time in England. Methods In this retrospective cohort study, we included all adults ([≥]18 years) in England with a positive Covid-19 test result between 1st October 2020 and 30th April 2021. Data were linked to primary and secondary care electronic health records and death registrations. Our outcomes were i) one or more emergency hospital admissions and ii) death from any cause, within 28 days of a positive test. Multivariable multilevel logistic regression was used to model each outcome with patient risk factors and time. Results 2,311,282 people were included in the study, of whom 164,046 (7.1%) were admitted and 53,156 (2.3%) died within 28 days. There was significant variation in the case hospitalisation and mortality risk over time, peaking in December 2020-February 2021, which remained after adjustment for individual risk factors. Older age groups, males, those resident in more deprived areas, and those with obesity had higher odds of admission and mortality. Of risk factors examined, severe mental illness and learning disability had the highest odds of admission and mortality. Conclusions In one of the largest studies of nationally representative Covid-19 risk factors, case hospitalisation and mortality risk varied significantly over time in England during the second pandemic wave, independent of the underlying risk in those infected.

Population level impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in the people with covid-19 in England: a national analysis using a stepped wedge design (preprint)

Objectives To identify the population level impact of a national pulse oximetry remote monitoring programme for covid-19 (COVID Oximetry @home; CO@h) in England on mortality and health service use. Design Retrospective cohort study using a stepped wedge pre- and post- implementation design. Setting All Clinical Commissioning Groups (CCGs) in England implementing a local CO@h programme. Participants 217,650 people with a positive covid-19 polymerase chain reaction test result and symptomatic, from 1st October 2020 to 3rd May 2021, aged [≥]65 years or identified as clinically extremely vulnerable. Care home residents were excluded. Interventions A pre-intervention period before implementation of the CO@h programme in each CCG was compared to a post-intervention period after implementation. Main outcome measures Five outcome measures within 28 days of a positive covid-19 test: i) death from any cause; ii) any A&E attendance; iii) any emergency hospital admission; iv) critical care admission; and v) total length of hospital stay. Results Implementation of the programme was not associated with mortality or length of hospital stay. Implementation was associated with increased health service utilisation with a 12% increase in the odds of A&E attendance (95% CI: 6%-18%) and emergency hospital admission (95% CI: 5%-20%) and a 24% increase in the odds of critical care admission in those admitted (95% CI: 5%-47%). In a secondary analysis of CO@h sites with at least 10% or 20% of eligible people enrolled, there was no significant association with any outcome measure. However, uptake of the programme was low, with enrolment data received for only 5,527 (2.5%) of the eligible population. Conclusions At a population level, there was no association with mortality following implementation of the CO@h programme, and small increases in health service utilisation were observed. Low enrolment of eligible people may have diluted the effects of the programme at a population level.

Evaluating the impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in patients with covid-19 assessed in Accident and Emergency departments in England: a retrospective matched cohort study (preprint)

Objectives To identify the impact of a national pulse oximetry remote monitoring programme for covid-19 (COVID Oximetry @home; CO@h) on health service use and mortality in patients attending Accident and Emergency (A&E) departments. Design Retrospective matched cohort study of patients enrolled onto the CO@h pathway from A&E. Setting National Health Service (NHS) A&E departments in England. Participants All patients with a positive covid-19 test from 1st October 2020 to 3rd May 2021 who attended A&E from three days before to ten days after the date of the test. All patients who were admitted or died on the same or following day to the first A&E attendance within the time window were excluded. Interventions Participants enrolled onto CO@h were matched using demographic and clinical criteria to participants who were not enrolled. Main outcome measures Five outcome measures were examined within 28 days of first A&E attendance: i) death from any cause; ii) any subsequent A&E attendance; iii) any emergency hospital admission; iv) critical care admission; and v) length of stay. Results 15,621 participants were included in the primary analysis, of whom 639 were enrolled onto CO@h and 14,982 were controls. Odds of death were 52% lower in those enrolled (95% CI: 7%-75% lower) compared to those not enrolled on CO@h. Odds of any A&E attendance or admission were 37% (95% CI: 16-63%) and 59% (95% CI: 16-63%) higher, respectively, in those enrolled. Of those admitted, those enrolled had 53% (95% CI: 7%-76%) lower odds of critical care admission. There was no significant impact on length of stay. Conclusions These findings indicate that for patients assessed in A&E, pulse oximetry remote monitoring may be a clinically effective and safe model for early detection of hypoxia and escalation, leading to increased subsequent A&E attendance and admissions, and reduced critical care requirement and mortality.

Use and impact of virtual primary care on quality and safety: public perspectives during the COVID-19 pandemic (preprint)

BackgroundWith the onset of COVID-19, primary care has swiftly transitioned from face-to-face to virtual care, yet it remains largely unknown how this has impacted on the quality and safety of care. AimTo evaluate patient use of virtual primary care models during COVID-19 in terms of change in uptake, perceived impact on the quality and safety of care, and willingness of future use. Design and settingAn online cross-sectional survey was administered to the public across the United Kingdom, Sweden, Italy and Germany. MethodsMcNemar tests were conducted to test pre- and post pandemic differences in uptake for each technology. One-way analysis of variance was conducted to examine patient experience ratings and perceived impacts on healthcare quality and safety across demographic characteristics. ResultsRespondents (N=6,326) reported an increased use of telephone consultations (+6.3%, P<.001), patient-initiated services (+1.5%, n=98, p<0.001), video consultations (+1.4%, P<.001), remote triage (+1.3, p<0.001), and secure messaging systems (+0.9%, P=.019). Experience rates using virtual care technologies were higher for men (2.39{+/-}0.96 vs 2.29{+/-}0.92, P<.001), those with higher literacy (2.75{+/-}1.02 vs 2.29{+/-}0.92, P<.001), and participants from Germany (2.54{+/-}0.91, P<.001). Healthcare timeliness and efficiency were the quality dimensions most often reported as being positively impacted by virtual technologies (60.2%, n=2,793 and 55.7%, n=2,401, respectively), followed by effectiveness (46.5%, n=1,802), safety (45.5%, n=1,822), patient-centredness (45.2%, n=45.2) and equity (42.9%, n=1,726). Interest in future use was highest for telephone consultations (55.9%), followed by patient-initiated digital services (56.1%), secure messaging systems (43.4%), online triage (35.1%), video consultations (37.0%), and chat consultations (30.1%), although significant variation was observed between countries and patient characteristics. ConclusionFuture work must examine the drivers and determinants of positive experiences using remote care to co-create a supportive environment that ensures equitable adoption and use across different patient groups. Comparative analysis between countries and health systems offers the opportunity for policymakers to learn from best practices internationally.

Benefits and Challenges of Using Virtual Primary Care During the COVID-19 Pandemic: From Key Lessons to a Framework for Implementation (preprint)

Background: With the onset of COVID-19, general practitioners (GPs) and patients worldwide swiftly transitioned from face-to-face to digital remote consultations. There is a need to evaluate how this global shift has impacted patient care, healthcare providers, patient and carer experience, and health systems. Objective: We explored GPs' perspectives on the main benefits and challenges of using digital remote care. Methods: GPs across 20 countries completed an online questionnaire between June - September 2020. GPs' perceptions on main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. Results: 1,605 respondents participated in our survey. The benefits identified included reducing COVID-19 transmission risks, guaranteeing access and continuity of care, improved efficiency, faster access to care, improved convenience and communication with patients, greater work flexibility for providers, and hastening the digital transformation of primary care and the accompanying legal frameworks. Main challenges included patient's preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital remote care, and unsuitability for certain types of consultations. Other challenges include the lack of formal guidance, higher workloads, remuneration issues, organisational culture, technical difficulties, implementation and financial issues, and regulatory weaknesses. Conclusion: At the frontline of care delivery, GPs can provide important insights on what worked well, why, and how. Lessons learned during the emergency phase can be used to inform the stable adoption of virtual care solutions, and co-design processes and platforms that are technologically robust, secure, and supported by a strategic long-term plan.

Using big data analytics to explore the relationship between government stringency and preventative social behaviour during the COVID-19 pandemic in the United Kingdom (preprint)

We evaluated the association between preventative social behaviour and government stringency. Additionally, we sought to evaluate the influence of additional factors including time, need to protect others (using the reported number of COVID-19 deaths as a surrogate measure) and reported confidence in government handling of the COVID-19 pandemic. We used repeated national cross-sectional surveys the UK over the course of 41 weeks from 1st April 2020 to January 28th, 2021, including a total of 38,092 participants. Preventative social behaviour and government stringency index scores were significantly associated on linear regression analyses (R2 =0.6468, p<0.001, and remained significant after controlling for the effect of reported COVID-19 deaths, confidence in government handling of the pandemic, and time (R2=0.898, p<0.001). Longitudinal data suggest that government stringency is an effective tool in promoting preventative social behaviour in the fight against COVID-19.

International attitudes on COVID-19 vaccination: repeat national cross-sectional surveys across 15 countries (preprint)

Objective: To examine the general publics views around willingness to receive COVID-19 vaccines and concerns regarding their safety. Design: Repeat cross-sectional surveys. Setting: Online surveys in Australia, Canada, Denmark, Finland, France, Germany, Italy, Japan, Netherlands, Norway, Singapore, South Korea, Spain, Sweden and the United Kingdom Participants: National samples of adults aged 18 years and above in November 2020 and January 2021. Main outcomes measures: The proportion of adults reporting: willingness to receive a COVID-19 vaccination; concern regarding side-effects from vaccinations; concerns over contraction COVID-19, and beliefs around vaccine provision in their country. Changes between the November and January surveys are also reported. Results: Across the 15 countries, the proportion of respondents reporting they would have the COVID-19 vaccine increased from 40.7% (range: 25.0-55.1) to 55.2% (range: 34.8-77.5), proportion reporting worried about the side-effects of vaccine decreased from 53.3% (range: 42.1-66.7) to 47.9% (range: 28.0-66.1). On the second survey, willingness to receive vaccine remained low in females (49.4%, range: 30.2-79.1), aged 18-39 years (42.1%, range: 25.9-71.7), those not working or unemployed (48.9, range: 18.8-67.0), students (45.9%, range: 22.8-70.0), and those with children at home (46.5%, range: 32.4-68.9). Concerns regarding safety of vaccine remained high in females (53.7%, range: 31.8-70.4), aged 18-39 years (50.8%, range: 28.2-60.7), aged 40-64 years (51.3%, range: 30.7-68.5), those working (50.5%, range: 26.7-65.0), those not working or unemployed (53.3, range: 35.4-73.8) and those with children at home (55.8%, range: 36.5-64.7). Conclusion: COVID-19 vaccine hesitancy decreased considerably over a relatively short time coinciding with the discovery of effective vaccines. The public remain concerned about their safety, and public health messaging will need to emphasis their safety especially amongst females, parents and younger adults.

COVID-19 surveillance - a descriptive study on data quality issues (preprint)

Background: High-quality data is crucial for guiding decision making and practicing evidence-based healthcare, especially if previous knowledge is lacking. Nevertheless, data quality frailties have been exposed worldwide during the current COVID-19 pandemic. Focusing on a major Portuguese surveillance dataset, our study aims to assess data quality issues and suggest possible solutions. Methods: On April 27th 2020, the Portuguese Directorate-General of Health (DGS) made available a dataset (DGSApril) for researchers, upon request. On August 4th, an updated dataset (DGSAugust) was also obtained. The quality of data was assessed through analysis of data completeness and consistency between both datasets. Results: DGSAugust has not followed the data format and variables as DGSApril and a significant number of missing data and inconsistencies were found (e.g. 4,075 cases from the DGSApril were apparently not included in DGSAugust). Several variables also showed a low degree of completeness and/or changed their values from one dataset to another (e.g. the variable underlying conditions had more than half of cases showing different information between datasets). There were also significant inconsistencies between the number of cases and deaths due to COVID-19 shown in DGSAugust and by the DGS reports publicly provided daily. Conclusions: The low quality of COVID-19 surveillance datasets limits its usability to inform good decisions and perform useful research. Major improvements in surveillance datasets are therefore urgently needed - e.g. simplification of data entry processes, constant monitoring of data, and increased training and awareness of health care providers - as low data quality may lead to a deficient pandemic control.