Multiscale mobility patterns and the restriction of human movement (preprint)

From the perspective of human mobility, the COVID-19 pandemic constituted a natural experiment of enormous reach in space and time. Here, we analyse the inherent multiple scales of human mobility using Facebook Movement Maps collected before and during the first UK lockdown. First, we obtain the pre-lockdown UK mobility graph, and employ multiscale community detection to extract, in an unsupervised manner, a set of robust partitions into flow communities at different levels of coarseness. The partitions so obtained capture intrinsic mobility scales with better coverage than NUTS regions, which suffer from mismatches between human mobility and administrative divisions. Furthermore, the flow communities in the fine scale partition match well the UK Travel to Work Areas (TTWAs) but also capture mobility patterns beyond commuting to work. We also examine the evolution of mobility under lockdown, and show that mobility first reverted towards fine scale flow communities already found in the pre-lockdown data, and then expanded back towards coarser flow communities as restrictions were lifted. The improved coverage induced by lockdown is well captured by a linear decay shock model, which allows us to quantify regional differences both in the strength of the effect and the recovery time from the lockdown shock.

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.

Democratic governance and excess mortality during the COVID-19 pandemic (preprint)

BackgroundExcess mortality has been used to assess the health impact of COVID-19 across countries. Democracies aim to build trust in government and enable checks and balances on decision-making, which may be useful in a pandemic. On the other hand, democratic governments have been criticised as slow to enforce restrictive policies and being overly influenced by public opinion. This study sought to understand whether strength of democratic governance is associated with the variation in excess mortality observed across countries during the pandemic. MethodsThrough linking open-access datasets we constructed univariable and multivariable linear regression models investigating the association between country EIU Democracy Index (representing strength of democratic governance on a scale of 0 to 10) and excess mortality rates, from February 2020 to May 2021. We stratified our analysis into high-income and low and middle-income country groups and adjusted for several important confounders. ResultsAcross 78 countries, the mean EIU democracy index was 6.74 (range 1.94 to 9.81) and the mean excess mortality rate was 128 per 100,000 (range -55 to 503 per 100,000). A one-point increase in EIU Democracy Index was associated with a decrease in excess mortality of 26.3 per 100,000 (p=0.002), after accounting for COVID-19 cases, age [≥] 65, gender, prevalence of cardiovascular disease, universal health coverage and the strength of early government restrictions. This association was particularly strong in high-income countries ({beta} -47.5, p<0.001) but non-significant in low and middle-income countries ({beta} -10.8, p=0.40). ConclusionsSocio-political factors related to the way societies are governed have played an important role in mitigating the overall health impact of COVID-19. Given the omission of such considerations from outbreak risk assessment tools, and their particular significance in high-income countries rated most highly by such tools, this study strengthens the case to broaden the scope of traditional pandemic risk assessment. Key MessagesO_ST_ABSWhat is already known?C_ST_ABSO_LIPrevious studies have found that as countries become more democratic they experience a decline in rates of infant and child mortality, infections such as tuberculosis, and non-communicable diseases. C_LIO_LIIn Europe, more democratic countries were initially more reluctant to adopt restrictive COVID-19 measures that could conflict with democratic principles, including lockdowns. C_LI What are the new findings?O_LIWe found that a one-point increase in EIU Democracy Index was associated with a decrease in excess mortality of 26.3 per 100,000 (p=0.002), after accounting for several confounders including demographics, numbers of cases and the strength of early government responses. C_LIO_LIThis association was particularly significant in high-income countries ({beta} - 47.5, p<0.001), suggesting that way societies are governed has played an important role in mitigating the impact of COVID-19. C_LI What do the new findings imply?O_LIGiven the omission of social, political and cultural considerations from outbreak risk assessment tools, and criticisms of such tools that have failed to accurately reflect the observed impact of the pandemic across high-income countries, this study builds on the case to broaden of the scope of traditional pandemic risk assessment. C_LIO_LIFuture research into the mechanisms underlying our findings will help to understand and address the complex and deep-rooted vulnerabilities countries face in a protracted and large-scale public health emergency. C_LI

Assessing the Safety of Home Oximetry for Covid-19: A multi-site retrospective observational study. (preprint)

ObjectivesTo determine the safety and effectiveness of home oximetry monitoring pathways safe for Covid-19 patients in the English NHS DesignThis was a retrospective, multi-site, observational study of home oximetry monitoring for patients with suspected or proven Covid-19 SettingThis study analysed patient data from four Covid-19 home oximetry pilot sites in North West London, Slough, South Tees and Watford across primary and secondary care settings. Participants1338 participants were enrolled in a home oximetry programme at one of the four pilot sites. Participants were excluded if primary care data and oxygen saturations are rest at enrolment were not available. 908 participants were included in the analysis. InterventionsHome oximetry monitoring was provided to participants with a known or suspected diagnosis of Covid-19. Participants were enrolled following attendance to accident and emergency departments, hospital admission or referral through primary care services. ResultsOf 908 patients enrolled into four different Covid-19 home oximetry programmes in England, 771 (84.9%) had oxygen saturations at rest of 95% or more, and 320 (35.2%) were under 65 years of age and without comorbidities. 52 (5.7%) presented to hospital and 28 (3.1%) died following enrolment, of which 14 (50%) had Covid-19 as a named cause of death. All-cause mortality was significantly higher in patients enrolled after admission to hospital (OR 8.70, 95% CI: 2.5 - 29.9), compared to those enrolled in primary care, Patients enrolled after hospital discharge (OR 0.31, 95% CI: 0.15 - 0.68) or emergency department presentation (OR 0.42, 95% CI: 0.20 - 0.89) were significantly less likely to present to hospital after enrolment than those enrolled in primary care. ConclusionsThis study find that home oximetry monitoring can be a safe pathway for Covid-19 patients; and indicates increases in risk to vulnerable groups and patients with oxygen saturations < 95% at enrolment, and in those enrolled on discharge from hospital. Findings from this evaluation have contributed to the national implementation of home oximetry across England, and further work will be undertaken to evaluate clinical effectiveness of the new pathway. Section 1: What is already known on this topicO_LIThe Covid-19 pandemic has created a new and significant burden on health systems globally. C_LIO_LIOxygen saturations have been found to be an important factor to stratify patient risk and guide treatment of Covid-19. C_LIO_LIHome oximetry programmes emerged during the early stages of the pandemic as an innovative means of monitoring patients with Covid-19 without admission to hospital. C_LI Section 2: What this study addsO_LIHome oximetry monitoring is associated with low rates of hospitalisation (5.7%) and all-cause mortality (3.1%). Many low-risk patients were enrolled in home oximetry pilots, and were associated with low rates of mortality. C_LIO_LIHome oximetry monitoring may represent a safe and programme for the delivery of community care to Covid-19 patients with pre-existing risk factors including increased age, high BMI and clinical comorbidities but who do not meet clinical thresholds for hospital admission. C_LI

Bridging the Digital Divide: A National Survey Assessing Public Readiness for Digital Health Strategies Against COVID-19 within the United Kingdom (preprint)

Digital health technologies are a major feature of contemporary public health strategies, particularly in relation to the COVID-19 pandemic. However, digital initiatives risk excluding vulnerable groups, thereby propagating poor health outcomes. We assessed how groups at higher risk from COVID-19 report their relationships with key digital health initiatives in the United Kingdom. We found that those who are female, over 60 and of a lower social group are less confident in using digital information to make health decisions. Those over 40, from lower social groups and of lower educational attainment use digital resources less often in seeking COVID-19 health information. Lastly, those over 60, from lower social groups and of lower educational attainment are less confident in distinguishing reliable digital COVID-19 information. This suggests that a ‘digital first’ model of COVID-19 pandemic management may exacerbate existing digital and health inequalities by reinforcing barriers to health information and public health services.

DETERMINANTS OF BURNOUT AND OTHER ASPECTS OF PSYCHOLOGICAL WELL-BEING IN HEALTHCARE WORKERS DURING THE COVID-19 PANDEMIC: A MULTINATIONAL CROSS-SECTIONAL STUDY (preprint)

BackgroundThe Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. MethodsFrom 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. ResultsOf 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and other clinical (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Factors significantly protective for burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. ConclusionOur findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.

What Has Been the Impact of Covid-19 on Safety Culture? (preprint)

Introduction Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and in turn patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. Methods The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture during Covid-19 at a large UK teaching hospital. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. Results Significant increases were seen in SAQ score for doctors and AHPs (p value) from baseline (p value). A decrease in SAQ was found in the nursing group. Largely due to perception of management and safety climate subscales. During Covid-19, on univariate regression analysis, female gender (p<0.001), age 40-49 years (p<0.01), non-white ethnicity (p<0.001), nursing job role (p<0.001) were all associated with lower SAQ scores. Training (p<0.001) and support (p<0.001) for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13, -0.26-0.00), non-disclosed ethnicity (-0.11, -0.22-0.00), nursing role (-0.15, -0.24-0.06), and support (0.24, 0.07-0.4) persisted to significance. A significant decrease (p<0.003) was seen in error reporting after the onset of the Covid-19 pandemic. Discussion Differences in reported safety culture may reflect perception of risk due to: occupational exposure, job function, or access to support services. Reductions in incident reporting may be due to increased workload, change in nature of work, or changing safety attitudes. Targeted high-quality support for redeployed staff may help improve safety during future pandemics.

How should hospitals manage the backlog of patients awaiting surgery following the COVID-19 pandemic? A demand modelling simulation case study for carotid endarterectomy (preprint)

Background The COVID-19 pandemic presents unparalleled challenges for the delivery of safe and effective care. In response, many health systems have chosen to restrict access to surgery and reallocate resources; the impact on the provision of surgical services has been profound, with huge numbers of patient now awaiting surgery at the risk of avoidable harm. The challenge now is how do hospitals transition from the current pandemic mode of operation back to business as usual, and ensure that all patients receive equitable, timely and high-quality surgical care during all phases of the public health crisis. Aims and Methods This case study takes carotid endarterectomy as a time-sensitive surgical procedure and simulates 400 compartmental demand modelling scenarios for managing surgical capacity in the UK for two years following the pandemic. Results A total of 7,69 patients will require carotid endarterectomy. In the worst-case scenario, if no additional capacity is provided on resumption of normal service, the waiting list may never be cleared, and no patient will receive surgery within the 2-week target; potentially leading to >1000 avoidable strokes. If surgical capacity is doubled after 1-month of resuming normal service, it will still take more than 6-months to clear the backlog, and 30.8% of patients will not undergo surgery within 2-weeks, with an average wait of 20.3 days for the proceeding 2 years. Conclusions This case study for carotid endarterectomy has shown that every healthcare system is going to have to make difficult decisions for balancing human and capital resources against the needs of patients. It has demonstrated that the timing and size of this effort will critically influence the ability of these systems to return to their baseline and continue to provide the highest quality care for all. The failure to sustainably increase surgical capacity early in the post-COVID-19 period will have significant long-term negative impacts on patients and is likely to result in avoidable harm.