ABSTRACT
BackgroundLocal Healthwatch organisations are an important part of the landscape of health and care commissioning and provision in England. In addition, local Healthwatch organisations are a key means by which users of services are given voice to influence decisions about health and care commissioning and provision.ObjectiveWe aimed to explore and enhance the operation and impact of local Healthwatch in ensuring effective patient and public voice in the commissioning and provision of NHS services.DesignWe used mixed methods, including a national survey (96/150 responses, 68%);actor network theory-inspired ethnographic data collection in five local Healthwatch organisations (made up of 75 days' fieldwork, 84 semistructured interviews, 114 virtual interviews, observations during the COVID-19 pandemic and documentary analysis) and serial interviews about experiences during the pandemic with 11 Healthwatch staff and four volunteers who were members of a Healthwatch Involvement Panel (which also guided data collection and analysis). Finally, we ran five joint interpretive forums to help make sense of our data.SettingOur five Healthwatch case study organisations are of varying size and organisational form and are located in different parts of England.ResultsWe found significant variation in the organisation and work of Healthwatch organisations nationally, including hosting arrangements, scale of operations, complexity of relationships with health and care bodies, and sources of income beyond core funding. Key points of divergence that were consequential for Healthwatch activities included the degree of autonomy from host organisations and local understandings of accountability to various constituencies. These points of divergence gave rise to very different modes of operation and different priorities for enacting the nationally prescribed responsibilities of Healthwatch organisations locally. Large variations in funding levels created Healthwatch organisations that diverged not just in scale but in focus. As the COVID-19 pandemic unfolded, Healthwatch found new approaches to giving voice to the views of the public and formed effective relationships with other agencies.RecommendationsWe identified generalisable principles of good practice regarding the collection and communication of evidence. Policy implications relate to (1) the overall funding regime for Healthwatch and potential inequalities in what is available to local populations and (2) the development of Healthwatch's role given the evolution of local health and care systems since 2012.Future workFuture studies should explore (1) the consequences of the development of integrated care systems for local Healthwatch organisations, (2) Healthwatch in an international comparative perspective, (3) how the response to the COVID-19 pandemic has reconfigured the voluntary sector locally and (4) how Healthwatch responds formally and informally to a newly emerging focus on public health and health inequalities.LimitationsThe survey sought only self-reported information on impact and we were unable to recruit a Healthwatch that hosted several contracts.ConclusionsThe diversity of the Healthwatch network belies its otherwise unitary appearance. This diversity – especially in differential funding arrangements – has considerable implications for equity of access to influencing health and care planning and provision for residents across England.FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 32. See the NIHR Journals Library website for further project information.
ABSTRACT
COVID-19 is a novel threat to human health worldwide. There is an urgent need to understand patient characteristics of having COVID-19 disease and evaluate markers of critical illness and mortality. Objective: To assess association of clinical features on patient outcomes. Design, Setting, and Participants: In this observational case series, patient-level data were extracted from electronic medical records for 28,336 patients tested for SARS-CoV-2 at the Mount Sinai Health System from 2/24/ to 4/15/2020, including 6,158 laboratory-confirmed cases. Exposures: Confirmed COVID-19 diagnosis by RT-PCR assay from nasal swabs. Main Outcomes and Measures: Effects of race on positive test rates and mortality were assessed. Among positive cases admitted to the hospital (N = 3,273), effects of patient demographics, hospital site and unit, social behavior, vital signs, lab results, and disease comorbidities on discharge and death were estimated. Results: Hispanics (29%) and African Americans (25%) had disproportionately high positive case rates relative to population base rates (p<2e-16); however, no differences in mortality rates were observed in the hospital. Outcome differed significantly between hospitals (Gray's T=248.9; p<2e-16), reflecting differences in average baseline age and underlying comorbidities. Significant risk factors for mortality included age (HR=1.05 [95% CI, 1.04-1.06]; p=1.15e-32), oxygen saturation (HR=0.985 [95% CI, 0.982-0.988]; p=1.57e-17), care in ICU areas (HR=1.58 [95% CI, 1.29-1.92]; p=7.81e-6), and elevated creatinine (HR=1.75 [95% CI, 1.47-2.10]; p=7.48e-10), alanine aminotransferase (ALT) (HR=1.002, [95% CI 1.001-1.003]; p=8.86e-5) and body-mass index (BMI) (HR=1.02, [95% CI 1.00-1.03]; p=1.09e-2). Asthma (HR=0.78 [95% CI, 0.62-0.98]; p=0.031) was significantly associated with increased length of hospital stay, but not mortality. Deceased patients were more likely to have elevated markers of inflammation. Baseline age, BMI, oxygen saturation, respiratory rate, white blood cell (WBC) count, creatinine, and ALT were significant prognostic indicators of mortality. Conclusions and Relevance: While race was associated with higher risk of infection, we did not find a racial disparity in inpatient mortality suggesting that outcomes in a single tertiary care health system are comparable across races. We identified clinical features associated with reduced mortality and discharge. These findings could help to identify which COVID-19 patients are at greatest risk and evaluate the impact on survival.