Retaining dermatology patients in primary care using dialogues with secondary care: A service evaluation (preprint)

Summary Background Wait list sizes for specialist secondary care have soared in recent years. Dermatology is a good candidate service for retaining patients in primary care and avoiding unnecessary waits to see a specialist. A dermatology dialogue service between primary and secondary care (DDPS) was developed in Norfolk and Waveney, eastern England. The service involved primary care referrers uploading patient images of skin complaints for review by and dialogue with secondary specialists to see if the patient could be retained in primary care, or should be referred to secondary care routinely, urgently or on the two week wait cancer pathway. Objectives To evaluate service performance with respect to specific targets including reduction in secondary care wait list growth in the period March 2021-March 2022 inclusive. Methods Service activity was summarized with respect to speed of resolution, case counts and dispositions. Clinician and patient satisfaction were canvased with structured questionnaires. Actual new referral counts were compared to projections based on historical data. Wait list growth was compared to other specialisms and other areas. Wait times to receive first treatment at start and end of monitoring period were monitored. Results Over 3600 patients were enrolled in the DDPS system. Over 98% of cases were reported by the dermatologists within 36 hours. Clinician and patient satisfaction were high. Frequently asked questions and conditions were highlighted by dermatologists to design and deliver an educational event for primary care clinicians that was well received. Wait list growth to see dermatology in the commissioning area was smaller for dermatology than other large specialisms, and mostly smaller growth than dermatology wait lists commissioned by other NHS commissioners. Negative impact on the urgent priority (cancer pathway) wait list could not be observed. Conclusions The DDPS was satisfactory to clinicians and patients and coincided with smaller dermatology wait list growth than might otherwise have been expected.

Feasibility and evaluation of an emergency department-based GP streaming and treatment service (preprint)

BACKGROUND Emergency departments (EDs) are under ever-increasing pressure. The General Practitioner Streaming and Treatment (GPST) service implemented at a large ED in England UK aimed to identify and treat patients who attended an ED but who might effectively be managed in primary care to reduce pressure on ED services. METHODS Patients attending ED were met by a GP nurse practitioner who ‘streamed’ them to the GPST service or usual ED care. Routinely collected electronic records, satisfaction questionnaires and interviews were used to evaluate patient outcomes, staff experiences, service outcomes and impacts on usual ED services. RESULTS Approximately 96% of GPST patients were seen by a clinician within one hour and all within 87 minutes. Routinely collected ED datasets indicate statistically significant reductions in patients streamed to usual ED care who had to wait > 4 hours for disposition (p=<0.005). Of 769 patients with GPST consultation (approximately 10% of all walk-in patients) 421 (55%) needed no further intervention by ED. The speed at which GPST patients were managed exceeded patients’ expectations and was a major determinant of their satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in patient eligibility criteria and built environment design features. CONCLUSIONS Concurrent provision of GPST correlated with shorter waits for ED attenders to receive health care. Patient and staff experiences of GPST were positive. A robust assessment of safety and health economic outcomes would be useful to refine eligibility criteria and cost effectiveness.

Super-spreaders of novel coronaviruses that cause SARS, MERS and COVID-19 : A systematic review (preprint)

ABSTRACT OBJECTIVE Most index cases with novel coronavirus infections transmit disease to just 1 or 2 other individuals, but some individuals ‘super-spread’ – they are infection sources for many secondary cases. Understanding common factors that super-spreaders may share could inform outbreak models. METHODS We conducted a comprehensive search in MEDLINE, Scopus and preprint servers to identify studies about persons who were each documented as transmitting SARS, MERS or COVID-19 to at least nine other persons. We extracted data from and applied quality assessment to eligible published scientific articles about super-spreaders to describe them demographically: by age, sex, location, occupation, activities, symptom severity, any underlying conditions and disease outcome. We included scientific reports published by mid June 2021. RESULTS The completeness of data reporting was often limited, which meant we could not identify traits such as patient age, sex, occupation, etc. Where demographic information was available, for these coronavirus diseases, the most typical super-spreader was a male age 40+. Most SARS or MERS super-spreaders were very symptomatic and died in hospital settings. In contrast, COVID-19 super-spreaders often had a very mild disease course and most COVID-19 super-spreading happened in community settings. CONCLUSION Although SARS and MERS super-spreaders were often symptomatic, middle- or older-age adults who had a high mortality rate, COVID-19 super-spreaders often had a mild disease course and were documented to be any adult age (from 18 to 91 years old). More outbreak reports should be published with anonymised but useful demographic information to improve understanding of super-spreading, super-spreaders, and the settings that super-spreading happens in.

Estimating the effectiveness of the Pfizer COVID-19 BNT162b2 vaccine after a single dose. A reanalysis of a study of ‘real-world’ vaccination outcomes from Israel (preprint)

A distinctive feature of the roll out of vaccination against SARS-CoV-2 virus in the UK was the decision to delay the timing of the second injection till 12 weeks after the first. The logic behind this is to protect more people sooner and so reduce the total number of severe infections, hospitalisations, and deaths. This decision caused criticism from some quarters due in part to a belief that a single injection may not give adequate immunity. A recent paper based on Israel’s experience of vaccination suggested that a single dose may not provide adequate protection. Here we extract the primary data from the Israeli paper and then estimate the incidence per day for each day after the first injection and also estimate vaccine effectiveness for each day from day 13 to day 24. We used a pooled estimate of the daily incidence rate during days 1 to 12 as the counterfactual estimate of incidence without disease and estimated confidence intervals using Monte Carlo modelling. After initial injection case numbers increased to day 8 before declining to low levels by day 21. Estimated vaccine effectiveness was pretty much 0 at day 14 but then rose to about 90% at day 21 before levelling off. The cause of the initial surge in infection risk is unknown but may be related to people being less cautious about maintaining protective behaviours as soon as they have the injection. What our analysis shows is that a single dose of vaccine is highly protective, although it can take up to 21 days to achieve this. The early results coming from Israel support the UK policy of extending the gap between doses by showing that a single dose can give a high level of protection.

Testing for SARS-CoV-2 in care home staff and residents in English care homes: A service evaluation (preprint)

Background COVID-19 has especially affected care home residents. Aim To evaluate a nurse-led Enhanced Care Home Team (ECHT) enhanced SARS-CoV-2 testing strategy. Design and setting Service evaluation in care homes in Norfolk UK. Method Residents and staff received nose and throat swab tests (7 April to 29 June 2020). Resident test results were linked with symptoms on days 0-14 after test and mortality to 13 July 2020. Results Residents (n=518) in 44 homes and staff (n=340) in 10 care homes were tested. SARS-CoV-2 positivity was identified in 103 residents in 14 homes and 49 staff in seven homes. Of 103 SARS-CoV-2+ residents, just 38 had typical symptom(s) at time of test (new cough and/or fever). Amongst 54 residents who were completely asymptomatic when tested, 12 (22%) developed symptoms within 14 days. Compared to SARS-CoV-2 negative residents, SARS-CoV-2+ residents were more likely to exhibit typical symptoms (new cough (n=26, p=0.001); fever (n=24, p=<0.001)) or as generally-unwell (n=18, p=0.001). Of 38 resident deaths, 21 (55%) were initially attributed to SARS-CoV-2, all of whom tested SARS-CoV-2+. One death not initially attributed to SARS-CoV-2 also tested positive. Conclusion Testing identified asymptomatic and pre-symptomatic SARS-CoV-2+ residents and staff. Being generally-unwell was common amongst symptomatic residents and may indicate SARS-CoV-2 infection in older people in the absence of more typical symptoms. Where a resident appears generally unwell SARS-CoV-2-infection should be suspected. Protocols for testing involved integrated health and social care teams.