ABSTRACT
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.
Subject(s)
COVID-19 , Obesity , Intellectual DisabilityABSTRACT
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.
Subject(s)
COVID-19ABSTRACT
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.
Subject(s)
COVID-19 , Hypoxia , DeathABSTRACT
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