A Novel Ontological Approach to Track Social Determinants of Health in Primary Care

The associated morbidity and mortality from COVID-19 and the public health response to prevent the spread of the virus has repeatedly demonstrated the significant impact of social determinants of health (SDoH) and social inequities on health outcomes. Social prescriptions are interventions aimed at tackling SDoH. In 2019, NHS-England committed to support the use of social prescribing across England. NHS-England commissioned the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) sentinel network to monitor the distribution of social prescribing services within English primary care and, within that, monitor the impact of the COVID-19 pandemic response on SDoH. To track incidence of people presenting to primary care with SDoH-related issues, we implemented an ontological approach to curate SDoH indicators in computerised medical records (CMR) using the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT). These indicators were then extracted from the RCGP-RSC sentinel network database to present weekly incidence rates per 10,000 people to assess the impact of the pandemic on these SDoH. Pre- versus peri-pandemic, we observed an increase in the recording of several of our SDoH indicators;namely issues related to homelessness, unemployment, mental health, harmful substance use and financial difficulties. As far as we are aware, this is the first time that routinely collected primary care CMR data has been utilised for the monitoring and surveillance of SDoH and demonstrates the feasibility of this approach for future surveillance. © 2022, Springer Nature Switzerland AG.

A Novel Ontological Approach to Estimate Inequalities and Underuse of Social Prescriptions for Mental Health in Primary Care in England

Mental health conditions are a significant contributor to morbidity and mortality and cost an estimated £1.6 trillion per year globally. The COVID-19 pandemic and its associated lockdowns have contributed to increases in common mental health problems (CMHP) like depression. Bodies in the UK recommend the use of non-medical interventions like social prescriptions to support individuals suffering from CMHP. In 2019, NHS-England committed to support the use of social prescribing across England. Despite this commitment, the proportion of eligible individuals with a CMHP that actually receive a social prescription remains unknown. To overcome this knowledge gap, a novel ontological approach was used to estimate the proportion of individuals with a CMHP that received a social prescription, disaggregated by different attributes (region, ethnicity, socio-economic status, sex, age) across a four-year period from 2017–2020. We discovered two general trends. First, there was a 1.4-fold increase in the presentation of individuals, across all attributes, to primary care with a CMHP across the four-year period analysed. There was also marked variation in the presentation to primary care with a CMHP based on different attributes (2020 variation figures - regions: 2.8-fold;ethnicity: 1.8-fold;socio-economic status: 1.4-fold;sex: 1.7-fold;age: 3.9-fold). Second, despite an increase in the use of social prescribing for mental health, there was still substantial underuse of it across all attributes in England (the highest percentage seen across all attributes in 2020 was 14%). The general trends revealed through our analyses provide valuable insights that can help to inform both policy and practice to address variation, health inequalities as well as to proactively design and implement appropriate services. © 2022, Springer Nature Switzerland AG.

De Novo Lower Urinary Tract Symptoms in COVID-19 Patients.

Background and objective Since early 2020, the novel coronavirus disease 2019 (COVID-19) has turned into a global healthcare concern. The usual clinical presentation of COVID-19 infection includes myalgia, headache associated with pyrexia, and sore throat. Our study aimed to assess the severity of lower urinary tract symptoms (LUTS) in COVID-19 patients and determine its correlation with the prognosis of the disease. Methods We conducted an observational study in the COVID-19 care unit at a tertiary care teaching center in Rajasthan on patients diagnosed as COVID-19-positive. The overactive bladder (OAB) symptom scoring system for LUTS and the CT scoring system for lung involvement in COVID-19 patients were used to evaluate the sample population. Results While our findings showed a non-significant association between OAB and CT score (p>0.05), correlation analysis revealed that the length of hospital stay was significantly longer and oxygen needs were significantly more frequent with severe LUTS. Conclusions Based on our findings, de novo LUTS, particularly storage symptoms, may be present in COVID-19-positive cases, and the severity of these symptoms may have an impact on the patient's length of stay in the hospital. Hence, doctors and other medical professionals should consider COVID-19-related bladder dysfunctions such as de novo LUTS as part of COVID-19 symptomatology.

Adverse events following first and second dose COVID-19 vaccination in England, October 2020 to September 2021: a national vaccine surveillance platform self-controlled case series study.

BackgroundPost-authorisation vaccine safety surveillance is well established for reporting common adverse events of interest (AEIs) following influenza vaccines, but not for COVID-19 vaccines.AimTo estimate the incidence of AEIs presenting to primary care following COVID-19 vaccination in England, and report safety profile differences between vaccine brands.MethodsWe used a self-controlled case series design to estimate relative incidence (RI) of AEIs reported to the national sentinel network, the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub. We compared AEIs (overall and by clinical category) 7 days pre- and post-vaccination to background levels between 1 October 2020 and 12 September 2021.ResultsWithin 7,952,861 records, 781,200 individuals (9.82%) presented to general practice with 1,482,273 AEIs, 4.85% within 7 days post-vaccination. Overall, medically attended AEIs decreased post-vaccination against background levels. There was a 3-7% decrease in incidence within 7 days after both doses of Comirnaty (RI: 0.93; 95% CI: 0.91-0.94 and RI: 0.96; 95% CI: 0.94-0.98, respectively) and Vaxzevria (RI: 0.97; 95% CI: 0.95-0.98). A 20% increase was observed after one dose of Spikevax (RI: 1.20; 95% CI: 1.00-1.44). Fewer AEIs were reported as age increased. Types of AEIs, e.g. increased neurological and psychiatric conditions, varied between brands following two doses of Comirnaty (RI: 1.41; 95% CI: 1.28-1.56) and Vaxzevria (RI: 1.07; 95% CI: 0.97-1.78).ConclusionCOVID-19 vaccines are associated with a small decrease in medically attended AEI incidence. Sentinel networks could routinely report common AEI rates, contributing to reporting vaccine safety.

An electronic medical record-based intervention to improve hepatitis A vaccination rates in the emergency department during a regional outbreak.

BACKGROUND: In response to the severe hepatitis A outbreak that occurred in Michigan between August 2016 and September 2019, our multihospital health system implemented an electronic medical record (EMR)-based vaccination intervention across its nine emergency departments (EDs). The objectives were to explore the impact of this intervention on increasing vaccination rates among high-risk individuals and to assess the barriers to use of a computerised vaccine reminder system. METHODS: All patients who were 18 years or older were screened using an electronic nursing questionnaire. If a patient was at high risk based on the questionnaire, an electronic best practice advisory (BPA) would trigger and give the physician or advanced practice provider the option to order the hepatitis A vaccine. We explored the vaccination rates in the 24-month preintervention and the 18-month intervention periods. We then administered a survey to physicians, advanced practice providers and nurses evaluating their perceptions and barriers to use of the EMR intervention. RESULTS: During the preintervention period, 49 vaccines were ordered (5.5 per 100 000 patient visits) and 32 were administered (3.6 per 100 000 patient visits). During the intervention period, 574 865 patient visits (74.3%) were screened. 2494 vaccines (322 per 100 000 patient visits) were ordered, and 1205 vaccines (155 per 100 000 patients visits) were administered. Physicians and advanced practice providers were initially compliant with the BPA's use, but compliance declined over time. Surveys revealed that the major barrier to use was lack of time. CONCLUSIONS: EMR screening tools and BPAs can be used in the ED as an effective strategy to vaccinate high-risk individuals. This may be translatable to outbreaks of other vaccine-preventable illnesses like influenza, measles or SARS-CoV-2. Providing ongoing education about the public health initiative and giving feedback to physicians, advanced practice providers and nurses about tool compliance are needed to sustain the improvement over time.

Integrated virtual medical consultations versus traditional clinic care in a public and a private outpatient service.

Objectives: The iConnect Care programme provided integrated 'virtual care' (VC) for patients with chronic kidney disease (CKD) in the South Eastern Sydney Local Health District. VC is an alternative to outpatient care which expedites time to specialists' opinions and is safe. Comparing different outpatient care models is important to understand the role of telehealth and integrated care, especially following the COVID-19 pandemic. This study aimed to compare a VC model with existing CKD outpatient care. Design participants and setting: A multisite, comparative, retrospective cohort study with parallel groups. 374 patients with mild CKD were recruited (July 2013 and August 2015) from public and private outpatients and followed for 12 months (n=304) or via VC (n=70). Estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (ACR) were compared at baseline, 6 and 12 months. Results: At 12 months, no significant differences existed among groups in eGFR or ACR or haemoglobin, but serum creatinine was lower in the VC cohort. A significant difference existed in time to see a patient from time of referral; 7 days for VC clinic and 35-42 days for outpatient clinic. Patients interviewed felt VC was efficient and they were well managed. Conclusion: VC can be a faster mechanism to access a nephrologist and other specialists. It provided similar outcomes to outpatient care. VC represents an additional assessment and follow-up pathway supported in the community. Time to deliver is similar, but specific resources are needed. It has the potential to evolve into a standard component of chronic disease care.

Limited waiting areas in outpatient clinics: an intervention to incorporate the effect of bridging times in blueprint schedules.

BACKGROUND: Distancing measures enforced by the COVID-19 pandemic impose a restriction on the number of patients simultaneously present in hospital waiting areas. OBJECTIVE: Evaluate waiting area occupancy of an intervention that designs clinic blueprint schedules, in which all appointments of the pre-COVID-19 case mix are scheduled either digitally or in person under COVID-19 distancing measures, whereby the number of in-person appointments is maximised. METHODS: Preintervention analysis and prospective assessment of intervention outcomes were used to evaluate the outcomes on waiting area occupancy and number of in-person consultations (postintervention only) using descriptive statistics, for two settings in the Rheumatology Clinic of Sint Maartenskliniek (SMK) and Medical Oncology & Haematology Outpatient Clinic of University Medical Center Utrecht (UMCU). Retrospective data from October 2019 to February 2020 were used to evaluate the pre-COVID-19 blueprint schedules. An iterative optimisation and simulation approach was followed, based on integer linear programming and Monte Carlo simulation, which iteratively optimised and evaluated blueprint schedules until the 95% CI of the number of patients in the waiting area did not exceed available capacity. RESULTS: Under pre-COVID-19 blueprint schedules, waiting areas would be overcrowded by up to 22 (SMK) and 11 (UMCU) patients, given the COVID-19 distancing measures. The postintervention blueprint scheduled all appointments without overcrowding the waiting areas, of which 88% and 87% were in person and 12% and 13% were digitally (SMK and UMCU, respectively). CONCLUSIONS: The intervention was effective in two case studies with different waiting area characteristics and a varying number of interdependent patient trajectory stages. The intervention is generically applicable to a wide range of healthcare services that schedule a (series of) appointment(s) for their patients. Care providers can use the intervention to evaluate overcrowding of waiting area(s) and design optimal blueprint schedules to continue a maximum number of in-person appointments under pandemic distancing measures.

Quality initiative to improve emergency department sepsis bundle compliance through utilisation of an electronic health record tool.

INTRODUCTION: Sepsis is a common cause of emergency department (ED) presentation and hospital admission, accounting for a disproportionate number of deaths each year relative to its incidence. Sepsis outcomes have improved with increased recognition and treatment standards promoted by the Surviving Sepsis Campaign. Due to delay in recognition and other barriers, sepsis bundle compliance remains low nationally. We hypothesised that a targeted education intervention regarding use of an electronic health record (EHR) tool for identification and management of sepsis would lead to increased EHR tool utilisation and increased sepsis bundle compliance. METHODS: We created a multidisciplinary quality improvement team to provide training and feedback on EHR tool utilisation within our ED. A prospective evaluation of the rate of EHR tool utilisation was monitored from June through December 2020. Simultaneously, we conducted two retrospective cohort studies comparing overall sepsis bundle compliance for patients when EHR tool was used versus not used. The first cohort was all patients with intention-to-treat for any sepsis severity. The second cohort of patients included adult patients with time of recognition of sepsis in the ED admitted with a diagnosis of severe sepsis or septic shock. RESULTS: EHR tool utilisation increased from 23.3% baseline prior to intervention to 87.2% during the study. In the intention-to-treat cohort, there was a statistically significant difference in compliance between EHR tool utilisation versus no utilisation in overall bundle compliance (p<0.001) and for several individual components: initial lactate (p=0.009), repeat lactate (p=0.001), timely antibiotics (p=0.031), blood cultures before antibiotics (p=0.001), initial fluid bolus (p<0.001) and fluid reassessment (p<0.001). In the severe sepsis and septic shock cohort, EHR tool use increased from 71.2% pre-intervention to 85.0% post-intervention (p=0.008). CONCLUSION: With training, feedback and EHR optimisation, an EHR tool can be successfully integrated into current workflows and appears to increase sepsis bundle compliance.

Innovating medication reviews through a technology-enabled process.

Medication reviews are effective in improving the quality of medication use among older people. However, they are conducted to various standards resulting in a wide range of outcomes which limit generalisability of findings arising from research studies. There also appear to be funding and time constraints, lack of data storage for quality improvement purposes, and non-standardised reporting of outcomes, especially clinically relevant outcomes. Furthermore, the coronavirus disease-19 (COVID-19) pandemic has restricted many face-to-face activities, including medication reviews. This article introduces a technology-enabled approach to medication reviews that may overcome some limitations with current medication review processes, and also make it possible to conduct medication reviews during the COVID-19 pandemic by providing an alternate platform. The possible advantages of this technology-enabled approach, legislative considerations and possible implementation in practice are discussed.

Microneedle-based devices for point-of-care infectious disease diagnostics.

Recent infectious disease outbreaks, such as COVID-19 and Ebola, have highlighted the need for rapid and accurate diagnosis to initiate treatment and curb transmission. Successful diagnostic strategies critically depend on the efficiency of biological sampling and timely analysis. However, current diagnostic techniques are invasive/intrusive and present a severe bottleneck by requiring specialist equipment and trained personnel. Moreover, centralised test facilities are poorly accessible and the requirement to travel may increase disease transmission. Self-administrable, point-of-care (PoC) microneedle diagnostic devices could provide a viable solution to these problems. These miniature needle arrays can detect biomarkers in/from the skin in a minimally invasive manner to provide (near-) real-time diagnosis. Few microneedle devices have been developed specifically for infectious disease diagnosis, though similar technologies are well established in other fields and generally adaptable for infectious disease diagnosis. These include microneedles for biofluid extraction, microneedle sensors and analyte-capturing microneedles, or combinations thereof. Analyte sampling/detection from both blood and dermal interstitial fluid is possible. These technologies are in their early stages of development for infectious disease diagnostics, and there is a vast scope for further development. In this review, we discuss the utility and future outlook of these microneedle technologies in infectious disease diagnosis.

Recording COVID-19 consultations: review of symptoms, risk factors, and proposed SNOMED CT terms.

BACKGROUND: There is an urgent need for epidemiological research in primary care to develop risk assessment processes for patients presenting with COVID-19, but lack of a standardised approach to data collection is a significant barrier to implementation. AIM: To collate a list of relevant symptoms, assessment items, demographics, and lifestyle and health conditions associated with COVID-19, and match these data items with corresponding SNOMED CT clinical terms to support the development and implementation of consultation templates. DESIGN & SETTING: Published and preprint literature for systematic reviews, meta-analyses, and clinical guidelines describing the symptoms, assessment items, demographics, and/or lifestyle and health conditions associated with COVID-19 and its complications were reviewed. Corresponding clinical concepts from SNOMED CT, a widely used structured clinical vocabulary for electronic primary care health records, were identified. METHOD: Guidelines and published and unpublished reviews (N = 61) were utilised to collate a list of relevant data items for COVID-19 consultations. The NHS Digital SNOMED CT Browser was used to identify concept and descriptive identifiers. Key implementation challenges were conceptualised through a Normalisation Process Theory (NPT) lens. RESULTS: In total, 32 symptoms, eight demographic and lifestyle features, 25 health conditions, and 20 assessment items relevant to COVID-19 were identified, with proposed corresponding SNOMED CT concepts. These data items can be adapted into a consultation template for COVID-19. Key implementation challenges include: 1) engaging with key stakeholders to achieve 'buy in'; and 2) ensuring any template is usable within practice settings. CONCLUSION: Consultation templates for COVID-19 are needed to standardise data collection, facilitate research and learning, and potentially improve quality of care for COVID-19.

Multimodality imaging of coronavirus disease 2019 (COVID-19): a pictorial essay.

The coronavirus disease 19 (COVID-19) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or new coronavirus 2019 (2019-nCoV) is now a global pandemic with attendant morbidity, mortality, and socioeconomic disruption. Its features have been described on plain chest radiography, chest computed tomography (CT), chest ultrasonography, brain CT, brain magnetic resonance imaging, and fluorodeoxyglucose-positron emission tomography. Based on current evidence, imaging plays an ancillary role in the management of those with severe illness. This essay illustrates the imaging manifestations of COVID-19 pictorially.

Discussion on the design of special CT room for epidemic prevention in fever clinic to deal with COVID-19 / 中华医学科研管理杂志

Objective@#New infectious diseases have become a global problem that seriously threatens human life and health and social development, which greatly increases the demand of CT examination for outpatients with fever. Through the discussion of the examination room design of the special CT for epidemic prevention, it can provide reference for medical institutions and reduce cross infection.@*Methods@#Based on the requirements of CT equipment installation and environment, combined with the special requirements of epidemic prevention in fever clinic, the paper analyzed the location of examination room, room layout, site construction method, air purification and disinfection, intelligent image aided diagnosis of special CT for epidemic prevention, and put forward the design scheme.@*Results@#Through the detailed analysis of the key points of engineering technology and the requirements of infection prevention and control of CT examination room, the design scheme of the examination room was given.@*Conclusions@#The establishment of special CT for epidemic prevention can meet the needs of clinical examination and effectively reduce cross infection. The design scheme given in this paper has certain reference value and can provide effective help for medical institution.