A COVID-19 Telehealth Impact Study—Exploring One Year of Telehealth Experimentation

Importance: This three-part study characterizes the widespread implementation of telehealth during the first year of the COVID-19 pandemic, giving us insight into the role of telehealth as we enter a stage of “new normal” healthcare delivery in the U.S. Objective: The COVID-19 Telehealth Impact Study was designed to describe the natural experiment of telehealth adoption during the pandemic. Using a large claims data stream and surveys of providers and patients, we studied telehealth in all 50 states to inform healthcare leaders. Design, Setting, Participants: In March 2020, the MITRE Corporation and Mayo Clinic founded the COVID-19 Healthcare Coalition (C19HCC), to respond to the pandemic. We report trends using a dataset of over 2 billion healthcare claims covering over 50% of private insurance activity in the U.S. (January 2019-December 2020), along with key elements from our provider survey (July-August 2020) and patient survey (November 2020 - February 2021). Main Outcomes and Measures: There was rapid and widespread adoption of telehealth in Spring 2020 with over 12 million telehealth claims in April 2020, accounting for 49.4% of total health care claims. Providers and patients expressed high levels of satisfaction with telehealth. 75% of providers indicated that telehealth enabled them to provide quality care. 84% of patients agreed that quality of their telehealth visit was good. Results: Peak levels of telehealth use varied widely among states ranging from 74.9% in Massachusetts to 25.4% in Mississippi. Every clinical discipline saw a steep rise with the largest claims volume in behavioral health. Provision of care by out-of-state provider was common at 6.5% (October-December 2020). Providers reported multiple modalities of telehealth care delivery. 74% of patients indicated they will use telehealth services in the future. Conclusions and Relevance: Innovation shown by providers and patients during this period of rapid telehealth expansion constitutes a great natural experiment in care delivery with evidence supporting widespread clinical adoption and satisfaction on the part of both patients and clinicians. The authors encourage continued broad access to telehealth over the next 12 months to allow telehealth best practices to emerge, creating a more effective and resilient system of care delivery.

National and regional prevalence of SARS-CoV-2 antibodies in primary and secondary school children in England: the School Infection Survey, a national open cohort study, November 2021 (preprint)

Background Risk factors for infection and, therefore, antibody positivity rates will be different in children compared to adults. We aim to estimate national and regional prevalence of SARS-CoV-2 antibodies in primary (4-11-year-olds) and secondary (11-15-year-olds) school children between 10 November and 10 December 2021. Methods Cross-sectional surveillance in England using two stage sampling, firstly stratifying into regions and selecting local authorities, then selecting schools according to a stratified sample within selected local authorities. Participants were sampled using a novel oral fluid validated assay for SARS-CoV-2 spike and nucleocapsid IgG antibodies. Results 4,980 students from 117 state-funded schools (2,706 from 83 primary schools, 2,274 from 34 secondary schools) provided a valid sample. After weighting for age, sex and ethnicity, and adjusting for assay accuracy, the national prevalence of SARS-CoV-2 antibodies in primary school students, who were all unvaccinated, was 40.1% (95%CI; 37.3-43.0). Antibody prevalence increased with age (p<0.001) and were higher in urban than rural schools (p=0.01). In secondary school students, the adjusted, weighted national prevalence of SARS-CoV-2 antibodies was 82.4% (95%CI; 79.5-85.1); including 57.5% (95%CI; 53.9-61.1) in unvaccinated and 97.5% (95%CI; 96.1-98.5) in vaccinated students. Antibody prevalence increased with age (p<0.001), and was not significantly different in urban versus rural students (p=0.1). Conclusions Using a validated oral fluid assay, we estimated national and regional seroprevalence of SARS-CoV-2 antibodies in primary and secondary school students. In November 2021, 40% of primary school students and nearly all secondary school students in England had SARS-CoV2 antibodies through a combination of natural infection and vaccination.

UK Adherence Rates to Continuous Positive Airway Pressure Before and After the Start of the Coronavirus Pandemic

57 Figure 1Percentage of patients adherent at each time point over 3 months at each centre and at all centres combined in 2019 compared to 2020 Abbreviations: GSTT: Guy’s and St Thomas’s Hospital, MH: Manchester Hospital, CH: Conquest Hospital, MSH: Musgrove Park Hospital, DH: Derriford Hospial Comparisons assessed using a Chi-square test (*p<0.05, **p<0.01, ***p<0.001). Significant differences between between 2019 and 2020 values denoted by asterisk(s) above the value. Significant differences between 2019 values denoted by a solid line drawn between timepoints compared and asterisk(s) above bar, and similarly significant differences between 2020 values denoted by a dashed line between timepoints compared and asterisk(s) above bar[Figure omitted. See PDF]Abstract 57 Table 1Table of patient characteristics at each centreAbbreviations: GSTT: Guy’s and St Thomas’s Hospital, MH: Manchester Hospital, CH: Conquest Hospital, MSH: Musgrove Park Hospital, DH: Derriford Hospital. ESS: Epworth Sleepiness Score, OSA: Obstructive Sleep Apnoea, BMI: body mass index. Comparisons assessed using a Chi-square, Mann Whitney U or Kruskal Wallis test (*p<0.05, **p<0.01, ***p<0.001).Discussion3 month adherence rates are low -at best 50%. Rates have changed at some centres since the pandemic, with change varying depending on the treatment pathway modifications implemented.ReferencesWeaver TE & Sawyer AM. Adherence to continuous positive airway pressure treatment for obstructive sleep apnoea: implications for future interventions. The Indian Journal of Medical Research 2010;131:245-258.Attias D, Pepin JL & Pathak A. Impact of COVID-19 lockdown on adherence to continuous positive airway pressure by obstructive sleep apnoea patients. The European Respiratory Journal 2020;56: doi:10.1183/13993003.01607-2020

Why is non-suicidal self-injury more prevalent among women? Mediation and moderation analyses of psychological distress, emotion dysregulation, and impulsivity (preprint)

Objective Non-suicidal self-injury (NSSI) appears to be more common among women than men, though the underlying reasons for this remain unclear. In a community sample of young adults ( n =996, aged 18-30) assessed during the COVID-19 pandemic, we investigated gendered patterns in NSSI etiology. Methods Mediation and moderation analyses considered associations between past-year NSSI prevalence, gender, and putative mechanistic variables: self-reported psychological distress (K10), emotion dysregulation (DERS), and impulsivity (UPPS-P). Results Nearly twice as many women as men reported past-year NSSI (14.47% versus 7.78%). Women reported significantly higher psychological distress and significantly lower sensation seeking and positive urgency than men. Psychological distress partially statistically mediated the relationship between gender and past-year NSSI. Gender did not significantly moderate associations between self-reported distress, emotion dysregulation, or impulsivity and past-year NSSI. Past-year NSSI prevalence did not significantly decrease with age and we found no significant age by gender interaction. Conclusions Greater levels of NSSI in young women are explained by their greater levels of emotional distress. Women do not appear to be more likely than men to report NSSI due to differences in how they manage emotional distress: gender did not moderate the association between psychological distress and past-year NSSI, and there were no gender differences in emotion dysregulation or negative urgency. Furthermore, we show that NSSI remains prevalent beyond adolescence. Early interventions which reduce distress or improve distress tolerance, strengthen emotion regulation skills, and provide alternative coping strategies merit investigation for NSSI. Highlights Young women were significantly more likely to report past-year NSSI than young men Psychological distress partially mediated the relationship between gender and NSSI Gender did not moderate associations between putative mechanistic variables and NSSI

Experiences of NHS Mental Healthcare Workers During the Covid-19 Pandemic: Qualitative Study (preprint)

Background: The Covid-19 pandemic has imposed extraordinary strains on healthcare workers, but, in contrast with acute settings, relatively little attention has been given to those who work in mental health settings. We aimed to characterise the experiences of those working in English NHS secondary mental health services during the first wave of the pandemic.Methods: The design was a qualitative interview-based study. We conducted semi-structured, remote (telephone or online) interviews with 35 members of staff from NHS secondary (inpatient and community) mental health services in England. Analysis was based on the constant comparative method. Results: Participants reported wide-ranging changes in the organisation of secondary mental health care and the nature of work in response to the pandemic, including pausing of all services deemed to be “non-essential”, deployment of staff across services to new and unfamiliar roles, and moves to remote working. The quality of participants’ working life was impaired by increasing levels of daily challenge associated with trying to provide care in trying and constrained circumstances, the problems of forging new ways of working remotely, and constraints on ability to access informal support for decision-making. Participants were confronted with difficult dilemmas relating to clinical decision-making, prioritisation of care, and compromises in ability to perform the therapeutic function of their roles. Other dilemmas centred on trying to balance the risks of controlling infection with the need for human contact. Many reported features of moral injury linked to their perceived failures in providing the quality or level of care that they felt service users needed. They sometimes sought to compensate for deficits in care through increased advocacy, taking on additional tasks, or making exceptions, but this led to further personal strain.  Many experienced feelings of grief, helplessness, isolation, distress, and burnout. These problems were compounded by sometimes poor communication about service changes and by staff feeling that they could not take time off because of the potential impact on others. Some reported feeling poorly supported by organisations. Conclusions: Mental health workers faced multiple adversities during the pandemic that were highly consequential for their wellbeing. These findings help in identifying targets for support. 

Remote care for mental health: qualitative study with service users, carers and staff during the COVID-19 pandemic (preprint)

ABSTRACT Objectives To explore the experiences of service users, carers and staff seeking or providing secondary mental health services during the COVID-19 pandemic. Design Qualitative interview study, co-designed with mental health service users and carers. Methods We conducted semi-structured, telephone or online interviews with a purposively constructed sample; a peer researcher with lived experience conducted and analysed interviews with service users. Analysis was based on the constant comparison method. Setting NHS secondary mental health services in England between June and August 2020. Participants Of 65 participants, 20 had either accessed or needed to access English secondary mental healthcare during the pandemic; 10 were carers of people with mental health difficulties; 35 were members of staff working in NHS secondary mental health services during the pandemic. Results Experiences of remote care were mixed. Some service users valued the convenience of remote methods in the context of maintaining contact with familiar clinicians. Most participants commented that a lack of non-verbal cues and the loss of a therapeutic ‘safe space’ challenged therapeutic relationship building, assessments, and identification of deteriorating mental wellbeing. Some carers felt excluded from remote meetings and concerned that assessments were incomplete without their input. Like service users, remote methods posed challenges for clinicians who reported uncertainty about technical options and a lack of training. All groups expressed concern about intersectionality exacerbating inequalities and the exclusion of some service user groups if alternatives to remote care are lost. Conclusions Whilst remote mental healthcare is likely to become increasingly widespread in secondary mental health services, our findings highlight the continued importance of a tailored, personal approach to decisions about remote mental healthcare. Further research should focus on which types of consultations best suit face-to-face interaction, and for whom and why, and which can be provided remotely and by which medium. ARTICLE SUMMARY Strengths and limitations of this study Strengths include its qualitative approach in speaking to a large sample of participants with varied mental health difficulties, carers, and a diverse range of mental healthcare staff. Its novelty lies in a deep exploration of the views and experiences of remote mental healthcare during a pandemic. The methods are strengthened by the involvement of experts-by-experience and the use of peer research methods. We did not adopt a narrative method; the interviews were one-off conversations so we could not explore change as the pandemic progressed and people may have become accustomed to remote care. The study used remote methods to comply with UK lockdown regulations; this will have excluded some groups without the ability to engage remotely.

Risk Factors for Excess Deaths Among Older Adults Without Confirmed COVID-19 During Lockdown: A Retrospective Cohort Study (preprint)

Background: Besides deaths directly attributable to COVID-19, many excess deaths occurred during ‘lockdown’, the range of societal responses to the initial wave of the COVID-19 pandemic. Data regarding these excess deaths is sparse, but necessary in order to avoid them in future waves. We investigated what factors contributed to excess deaths of older patients during the initial 2020 lockdown beyond those attributable to confirmed COVID-19. We hypothesized that both physical diseases and mental disorders would contribute.Methods: We did a retrospective cohort study using data from the electronic clinical records from Cambridge and Peterborough NHS Foundation Trust (CPFT), UK (catchment area population ~ 0.86 million). Eligible patients were aged 65 years or over at baseline with at least 14 days’ follow-up, excluding patients diagnosed with confirmed or suspected SARS-CoV-2 infection. We defined a cohort exposed to COVID-19 lockdown comprising patients recorded in CPFT between March 23, 2020 and May 19, 2020, and compared their mortality with an cohort recorded in CPFT between January 13, 2020 and 10 March, 2020, unexposed to lockdown. We used Cox regression to estimate the association between risk factors and death. Controlled covariates included social demographic factors, smoking status, mental comorbidities, and physical comorbidities.Findings: In the two cohorts, 3,073 subjects were exposed to lockdown and 4,372 subjects were unexposed; the cohorts were followed up for an average of 74 days and 78 days, respectively. After controlling for confounding by sociodemographic factors, smoking status, mental comorbidities, and physical comorbidities, dementia patients suffered an additional 53% risk of death (HR = 1.53, 95% CI = 1.02-2.31), and patients with severe mental illness suffered an additional 123% risk of death (HR = 2.23, 95% CI = 1.42-3.49). No significant additional death risks were identified from physical comorbidities.Interpretation: During lockdown people with dementia or severe mental illness had a higher risk of excess death. This study suggests that such patients require additional support during a societal response to this and similar epidemics/pandemics. These data could inform future health service responses and policymaking to help prevent avoidable excess death during future outbreaks of similar infectious diseases.Funding Statement: SC’s, PBJ’s, and RNC’s research was supported by the Medical Research Council (grant MC_PC_17213 to RNC). PBJ is funded through the NIHR Applied Research Collaboration (ARC) East of England. This research was supported in part by the UK National Institute for Health Research (NIHR) Cambridge Biomedical Research Centre. Declaration of Interests: SC, EFE, PQ, and JRL declare no conflict of interest with this work. PBJ is a scientific advisory board member for Janssen and Recordati. BRU is clinical director for older people’s and adult community services at CPFT. He is clinical director of the Windsor Unit at Fulbourn Hospital (CPFT), which delivers clinical trials in dementia/mild cognitive impairment for academic and commercial organisations without personal benefit, and is the clinical lead for dementia for the NIHR Clinical Research Network (CRN) in the East of England. His salary is part-funded by the NIHR CRN. He has been principal investigator on trials for Axovant, Lilly, and EIP Pharma; his institution has benefited from payment for research carried out but he has not personally received any money. His wife is the lead for mental health for Suffolk Clinical Commissioning Group. RNC consults for Campden Instruments Ltd and receives royalties from Cambridge University Press, Cambridge Enterprise, and Routledge.Ethics Approval Statement: NHS Research Ethics 17/EE/0442

The Early Impact of COVID-19 on Mental Health and Community Physical Health Services and Their Patients’ Mortality in Cambridgeshire and Peterborough, UK (preprint)

BACKGROUND: COVID-19 has affected social interaction and healthcare worldwide.METHODS: We examined changes in presentations and referrals to the primary provider of mental health and community health services in Cambridgeshire and Peterborough, UK, plus service activity and deaths. We conducted interrupted time series analyses with respect to the UK “lockdown”. We examined changes in standardized mortality ratio for those with and without severe mental illness (SMI).OUTCOMES: Referrals and presentations to nearly all mental and physical health services dropped at lockdown, with evidence for changes in both supply (service provision) and demand (help-seeking). This was followed by an increase in demand for some services. This pattern was seen for all major forms of presentation to liaison psychiatry services, except for psychosis/mania and eating disorders, for which there was no evidence of change. Inpatient numbers fell, but new detentions under the Mental Health Act were unchanged. Many services shifted from face-to-face to remote contacts. Excess mortality, primarily in the over-70s, lagged slightly behind confirmed numbers of COVID-19 cases. There was a much greater increase in mortality for patients with SMI, which was not explained by ethnicity.INTERPRETATION: COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity. This may reflect a genuine reduction of need or a lack of help-seeking and pent-up demand. There has been a disproportionate increase in death among those with SMI during the pandemic.FUNDING: UK Medical Research Council and National Institute of Health Research.DECLARATION OF INTERESTS:  Several authors (PBJ, BRU, AM, ETB, ESO, JBD, CFH, FJT, RNC) are CPFT clinicians involved in delivering some of the services discussed here and two (BRU, FJT) are clinical directors and therefore involved in managing them.  PBJ is a scientific advisory board member for Johnson & Johnson and Recordati.  BRU is clinical director of the Windsor Unit at Fulbourn Hospital (CPFT), which delivers clinical trials in dementia/mild cognitive impairment for academic and commercial organisations without personal benefit, and is the clinical lead for dementia for the NIHR Clinical Research Network (CRN) in the East of England. His salary is part-funded by the NIHR CRN. He has been principal investigator on trials for Axovant, Lilly, and EIP Pharma; his institution has benefited from payment for research carried out but he has not personally received any money. His wife is the lead for mental health for Suffolk Clinical Commissioning Group.  AM’s salary is part-funded by the Anna Freud National Centre for Children and Families, a mental health charity.  ETB is a scientific advisory board member for Sosei Hepares, and was a half-time employee of GlaxoSmithKline until May 2019.  RNC consults for Campden Instruments Ltd and receives royalties from Cambridge University Press, Cambridge Enterprise, and Routledge.  SC, SB, EFO, JBD, CFH, FJT, JDA, MPS, and JRL have nothing else to disclose.ETHICS APPROVAL STATEMENT: De-identified data was extracted from CPFT clinical records by CPFT’s Information & Performance team and via the CPFT Research Database (NHS research ethics 17/EE/0442). The study was conducted under UK National Health Service Research Ethics approval (ref. 17/EE/0442).