Community-onset urinary tract infection in females in the context of COVID-19: a longitudinal population cohort study exploring case presentation, management, and outcomes (preprint)

Background COVID-19 affected the epidemiology of other infectious diseases and how they were managed. Urinary tract infection (UTI) is one of the most common infections treated in the community in England. We investigated the impact of the COVID-19 pandemic on UTI primary care consultations and outcomes in female patients. Methods and findings We analysed General Practice (GP) consultation and hospital admission records using the Whole Systems Integrated Care (WSIC) data in North West London between 2016 and 2021. We quantified the changes in UTI GP consultation rates using time series analysis before and during the pandemic. We assessed the outcomes of UTI, measured by subsequent bacteraemia and sepsis within 60 days, for consultations delivered face-to-face or remotely, with or without diagnostic tests recommended by the national guidelines, and with or without antibiotic treatment. Between January 2016 and December 2021, we identified 375,859 UTI episodes in 233,450 female patients. Before the COVID-19 pandemic (January 2016-February 2020), the UTI GP consultation rate stayed level at 522.8 cases per 100,000 population per month, with a seasonal pattern of peaking in October. Since COVID-19, (March 2020-December 2021), monthly UTI GP consultations declined when COVID-19 cases surged and rose when COVID-19 case fell. During the pandemic, the UTI consultations delivered face-to-face reduced from 72.0% to 29.4%, the UTI consultations with appropriate diagnostic tests, including urine culture and urinalysis, reduced from 17.3% to 10.4%, and the UTI cases treated with antibiotics reduced from 52.0% to 47.8%. The likelihood of antibiotics being prescribed was not affected by whether the consultation was delivered face-to-face or remotely but associated with whether there was a diagnostic test. Regardless of whether the UTI consultation occurred before or during the pandemic, the absence of antibiotic treatment for UTI is associated with a 10-fold increase in the risk of having bacteraemia or sepsis within 60 days, though the patients who consulted GPs for UTI during the pandemic were older and more co-morbid. Across the study period (January 2016-December 2021), nitrofurantoin remained the first-line antibiotic option for UTI. The percentage of non-prophylactic acute UTI antibiotic prescriptions with durations that exceeded the guideline recommendations was 58.7% before the pandemic, and 49.4% since. This led to 830,522 total excess days of treatment, account for 63.3% of all non-prophylactic acute antibiotics prescribed for UTI. Before the pandemic, excess antibiotic days of UTI drugs had been reducing consistently. However, this decline slowed down during the pandemic. Having a diagnostic test was associated with 0.6 less excess days of antibiotic treatment. Conclusions This analysis provides a comprehensive examination of management and outcomes of community-onset UTI in female patients, considering the changes in GP consultations during the COVID-19 pandemic. Our findings highlighted the importance of appropriate urine testing to support UTI diagnosis in symptomatic patients and initiation of antibiotic treatment with appropriate course duration. Continued monitoring is required to assess the overall impact on patients and health systems from the changed landscape of primary care delivery.

Capacity planning for acute hospital inpatient care and adult critical care in England: a descriptive study using hospital administrative data

Background At the beginning of the COVID-19 pandemic in March and April, 2020, there was a focus on accommodating an anticipated surge of patients with COVID-19 in acute hospitals. We aimed to estimate the potential for freeing up capacity in acute hospitals in England. Methods In this descriptive study, we used admitted patient and adult critical care records from Hospital Episode Statistics (a database containing details of attendances at National Health Service acute hospitals in England) from 2018/19 to estimate historical numbers of inpatients. Each admission was grouped into emergency, maternity, and elective, with elective split by the presence or absence of cancer in the primary diagnosis. We further stratified the population by age and frailty, which we estimated with an index using International Statistical Classification of Diseases and Related Health Problems (tenth revision) codes in diagnosis fields. We used the (then current) National Institute for Health and Care Excellence (NICE) 2020 guidance on critical care pathways as a framework to examine four scenarios that limited access to beds for specific patient groups. This study was approved by the Secretary of State and the Health Research Authority under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 to hold confidential data and analyse them for research purposes (CAG ref 15/CAG/0005). We have approval to use these data for research into the quality and safety of health care, from the London–South East Ethics Committee (REC ref 20/LO/0611). Findings Between April 1, 2018, and March 31, 2019, 8 957 521 adults were admitted (7 372 040 [82·3%] emergency, 295 598 [3·3%] elective with cancer, 850 964 [9·5%] elective without cancer, and 438 919 [4·9%] maternity admissions), and 974 038 critical care episodes were recorded. Our analysis suggested that up to 70% of all acute inpatient beds could be released if only maternity, cancer, and emergency patients younger than 65 years were admitted;if non-frail patients aged 65 years and older were also admitted, 41% of beds could be freed up. Similarly, if only maternity, cancer, and emergency patients younger than 65 years were admitted to critical care beds, that might free up to 56% of adult critical care beds;if non-frail patients aged 65 years and older were also admitted, 30% of critical care beds could be freed up. Interpretation Given a crisis in health-care capacity, it seemed appropriate to model some difficult options based on NICE guidelines. We identified scope for freeing up total acute and critical care beds by postponing elective non-cancer admissions as a short-term measure during the first wave of COVID-19 (March to June, 2020) in England. The NICE guidelines were criticised by patient groups and have since been updated (NG191). Administrative data can inform planning for future crises albeit with limitations on estimating individual patient need, and deep social and ethical considerations. Our estimates were incorporated into a modelling tool for hospital provision during the pandemic. Funding Dr Foster Intelligence.

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.

Changing patterns of bloodstream infections in the community and in acute care across two COVID-19 epidemic waves: a retrospective analysis (preprint)

Introduction We examined the epidemiology of community- and hospital-acquired bloodstream infections (BSIs) in COVID-19 and non-COVID-19 patients across two epidemic waves. Methods We analysed blood cultures, SARS-CoV-2 tests, and hospital episodes of patients presenting and admitted to a London hospital group between January 2020 and February 2021. We reported BSI incidence, as well as changes in sampling, case mix, bed and staff capacity, and COVID-19 variants. Results 34,044 blood cultures were taken. We identified 1,047 BSIs; 653 (62.4%) defined epidemiologically as community-acquired and 394 (37.6%) as hospital-acquired. BSI rates and community / hospital ratio were similar to those pre-pandemic. However, important changes in patterns were seen. Among community-acquired BSIs, Escherichia coli BSIs remained lower than pre-pandemic level during the two COVID-19 waves, however peaked following lockdown easing in May 2020, deviating from the historical trend of peaking in August. The hospital-acquired BSI rate was 100.4 per 100,000 patient-days across the pandemic, increasing to 132.3 during the first COVID-19 wave and 190.9 during the second, with significant increase seen in elective non-COVID-19 inpatients. Patients who developed a hospital-acquired BSI, including those without COVID-19, experienced 20.2 excess days of hospital stay and 26.7% higher mortality, higher than reported in pre-pandemic literature. In intensive care units (ICUs), the overall BSI rate was 311.8 per 100,000 patient-ICU days, increasing to 421.0 during the second wave, compared to 101.3 pre-COVID. The BSI incidence in those infected with the SARS-CoV-2 Alpha variant was similar to that seen with earlier variants. Conclusion The pandemic and national responses have had an impact on patterns of community- and hospital-acquired BSIs, in both COVID-19 and non-COVID-19 patients. Factors driving the observed BSI patterns are complex, including changed patient mix, deferred access to health care, and sub-optimal practice. Infection surveillance needs to consider key aspects of pandemic response and changes in healthcare access and practice.

North West London Covid-19 Vaccination Programme: Real-world evidence for Vaccine uptake and effectiveness. (preprint)

Objective To assess the early vaccine administration coverage and vaccine effectiveness and outcome data across an integrated care system of eight CCGs leveraging a unique population-level care dataset Design Retrospective cohort study. Setting Individuals eligible for COVID 19 vaccination in North West London based on linked primary and secondary care data. Participants 2,183,939 individuals eligible for COVID 19 vaccination Results During the NWL vaccine programme study time period 5.88% of individuals declined and did not receive a vaccination. Black or black British individuals had the highest rate of declining a vaccine at 16.14% (4,337). There was a strong negative association between deprivation and rate of declining vaccination (r=-0.94, p<0.01) with 13.5% of individuals declining vaccination in the most deprived postcodes compared to 0.98% in the least deprived postcodes. In the first six days after vaccination 344 of 389587 individuals tested positive for COVID-19 (0.09%). The rate increased to 0.13% (525/389,243) between days 7 and 13, before then gradually falling week on week. At 28 days post vaccination there was a 74% (HR 0.26 (0.19-0.35)) and 78% (HR 0.22 (0.18-0.27)) reduction in risk of testing positive for COVID -19 for individuals that received the Oxford/Astrazeneca and Pfizer/BioNTech vaccines respectively, when compared with unvaccinated individuals. After vaccination very low rates of hospital admission were seen in individuals testing positive for COVID-19 (0.01% of all patients vaccinated). Conclusions This study provides further evidence that a single dose of either the Pfizer/BioNTech vaccine or the Oxford/Astrazeneca vaccine is effective at reducing the risk of testing positive for COVID-19 up to 60 days across all adult age groups, ethnic groups, and risk categories in an urban UK population. There was no difference in effectiveness up to 28 days between the Oxford/Astrazeneca and Pfizer/BioNtech vaccines. In those declining vaccination higher rates were seen in those living in the most deprived areas and in Black and Black British groups. There was no definitive evidence to suggest COVID-19 was transmitted as a result of vaccination hubs during vaccine the administration roll-out in NWL, and the risk of contracting COVID-19 and/or becoming hospitalised after vaccination has been demonstrated to be very low in the vaccinated population.

Quality Social Connection as an 'Active Ingredient' in Digital Interventions for Young People With Depression and Anxiety: A Systematic Scoping Review and Meta-Analysis (preprint)

Background: A quality social connection (QSC) can influence outcomes in mental health support. Digital interventions may modify this influence, although conceptualisation and evidence on psychiatric outcomes is limited. We aimed to conceptualise and appraise evidence on digital QSC (D-QSC) for young people. Methods: Systematic scoping review and meta-analysis, with embedded stakeholder involvement, searching healthcare databases, websites and the grey literature. We included studies that explored QSC within a digital intervention as part of the prevention or treatment of depression and/or anxiety in 14-24-year olds. Findings: 5714 publications were identified and 42 were included. Of these, there were 23,319 participants. D-QSC translated into a five-component conceptual framework: Rapport, Identity and commonality, Valued interpersonal dynamic, Engagement and Responded to and accepted (RIVER). There was a significant decrease in depression (-25.6%, 95% CI [-0.352, -0.160], p<0.0005) and anxiety (-15.1%, 95% CI [-0.251, -0.051], p<0.0005). Heterogeneity was high. Literature and stakeholder evidence showcased D-QSC’s importance in the prevention and treatment of depression, though evidence was weaker for anxiety. Stakeholder insights highlighted that demographic, dynamic and environmental factors, including blended care, may influence D-QSC experiences and outcomes. Interpretation: D-QSC is an important and under-considered component for depression and anxiety outcomes. Whilst more research is required, the RIVER conceptual framework can inform standardised measures for D-QSC. These measures can be used in the development and evaluation of digital interventions for mental health, particularly during the COVID-19 pandemic, where necessary support will be increasingly provided in online spaces. Funding: This work was funded by a Wellcome Trust Mental Health Priority Area 'Active Ingredients' commission awarded to Dr Lindsay Dewa at Imperial College London.Declaration of Interests: No competing interest to declare.Ethics Approval Statement: The authors noted that ethical approval was not required.

The Impact of the COVID-19 Epidemic on Patterns of Attendance at Emergency Departments in Two Large London Hospitals: An Observational Study (preprint)

Background Hospitals in England have undergone considerable change to address the surge in demand imposed by the COVID-19 epidemic. The impact of this on emergency department (ED) attendances is unknown, especially for non-COVID-19 related emergencies.Methods We calibrated auto-regressive integrated moving average time-series models of ED attendances to Imperial College Healthcare NHS Trust (ICHNT) using historic (2015–2019) data. Forecasted trends were compared to present year ICHNT data for the period between March 12 (when England implemented the first COVID-19 public health measure) and May 31. We compared ICHTN trends with publicly available regional and national data. Lastly, we compared emergency admissions and in-hospital mortality at ICHNT during the present year to a historic 5-year average.Results ED attendances at ICHNT decreased by 35%, in keeping with the trend for ED attendances across all England regions, which fell by approximately 50%. For ICHNT, the decrease in attendances was mainly amongst those aged < 65 years and those arriving by their own means (e.g. personal or public transport). Increasing distance from postcode of residence to hospital was a significant predictor of reduced attendances. Non-COVID related emergency admissions to hospital after March 12 fell by 48%; there was an indication of a non-significant increase in non-COVID-19 crude mortality risk (RR 1.13, 95%CI 0.94–1.37, p = 0.19).Conclusions Our study finds strong evidence that emergency healthcare seeking has drastically changed across the population in England. At ICHNT, we find that a larger proportion arrived by ambulance and that hospitalisation outcomes of non-COVID patients did not differ from previous years. The extent to which these findings relate to ED avoidance behaviours compared to having sought alternative emergency health services outside of hospital remains unknown. National analyses and strategies to streamline emergency services in England going forward are urgently needed.