Using health administrative data to model associations and predict hospital admissions and length of stay for people with eating disorders.

BACKGROUND: Eating disorders are serious mental illnesses requiring a whole of health approach. Routinely collected health administrative data has clinical utility in describing associations and predicting health outcome measures. This study aims to develop models to assess the clinical utility of health administrative data in adult eating disorder emergency presentations and length of stay. METHODS: Retrospective cohort study on health administrative data in adults with eating disorders from 2014 to 2020 in Sydney Local Health District. Emergency and admitted patient data were collected with all clinically important variables available. Multivariable regression models were analysed to explore associations and to predict admissions and length of stay. RESULTS: Emergency department modelling describes some clinically important associations such as decreased odds of admission for patients with Bulimia Nervosa compared to Anorexia Nervosa (Odds Ratio [OR] 0.31, 95% Confidence Interval [95%CI] 0.10 to 0.95; p = 0.04). Admitted data included more predictors and therefore further significant associations including an average of 0.96 days increase in length of stay for each additional count of diagnosis/comorbidities (95% Confidence Interval [95% CI] 0.37 to 1.55; p = 0.001) with a valid prediction model (R2 = 0.56). CONCLUSIONS: Health administrative data has clinical utility in adult eating disorders with valid exploratory and predictive models describing associations and predicting admissions and length of stay. Utilising health administrative data this way is an efficient process for assessing impacts of multiple factors on patient care and predicting health care outcomes.

Assessing spatiotemporal variability in SARS-CoV-2 infection risk for hospital workers using routinely-collected data.

The COVID-19 pandemic has emphasised the need to rapidly assess infection risks for healthcare workers within the hospital environment. Using data from the first year of the pandemic, we investigated whether an individual's COVID-19 test result was associated with behavioural markers derived from routinely collected hospital data two weeks prior to a test. The temporal and spatial context of behaviours were important, with the highest risks of infection during the first wave, for staff in contact with a greater number of patients and those with greater levels of activity on floors handling the majority of COVID-19 patients. Infection risks were higher for BAME staff and individuals working more shifts. Night shifts presented higher risks of infection between waves of COVID-19 patients. Our results demonstrate the epidemiological relevance of deriving markers of staff behaviour from electronic records, which extend beyond COVID-19 with applications for other communicable diseases and in supporting pandemic preparedness.

Duration of influenza vaccine effectiveness in the elderly in Japan: A retrospective cohort study using large-scale population-based registry data.

BACKGROUND: The immune response to influenza vaccination in the elderly is likely to be lower than that in young adults. Clinical protection may not persist year-round in the elderly. However, the effectiveness of influenza vaccine in the elderly has not been adequately studied, especially in terms of the duration of effectiveness. METHODS: We used a linked database of healthcare administrative claims data and vaccination records maintained by the municipality of a city in Kanto region of Japan. We studied individuals who were aged 65 years or older at baseline and were followed up between April 1, 2014 to March 31, 2020. The duration of influenza vaccine effectiveness by age category was analyzed using a time-dependent piecewise Cox proportional hazard model with time-dependent vaccine status, prior season vaccination and covariates confirmed in the baseline period (age, sex, cancer, diabetes, chronic obstructive pulmonary diseases, asthma, chronic kidney diseases, and cardiovascular diseases). RESULTS: We identified an analysis population of 83,146 individuals, of which 7,401 (8.9%) had experienced influenza and 270 (0.32%) underwent influenza-related hospitalization. Individuals who were vaccinated during the first season (n = 47,338) were older than non-vaccinated individuals (n = 35,808) (average age, 75.8 vs. 74.1 years, respectively). The multivariable analysis showed a lower incidence of influenza in vaccinated individuals (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.43-0.51; P < 0.001), while the incidence of hospitalization for influenza did not differ significantly by vaccination status (HR, 0.79; 95% CI, 0.53-1.18; P = 0.249). Protective effectiveness against incidence was maintained for 4 or 5 months after vaccination in those aged 65-69 and 80-years, 5 months in 70-79 years. CONCLUSIONS: Our study identified moderate vaccine effectiveness in preventing the incidence of influenza in the Japanese elderly. Vaccine effectiveness showed a trend of gradual attenuation. Clinicians should suspect influenza infection even in those vaccinated, especially in elderly individuals who had received vaccination more than 4 or 5 months previously.

[Trends in place of death for nursing home residents in an urban district during the COVID-19 pandemic: An analysis of death registry data]. / Entwicklung der Sterbeorte von Pflegeheimbewohnern in einem städtischen Versorgungsbereich während der COVID-19-Pandemie ­ eine Auswertung von Daten des Sterberegisters.

BACKGROUND: The nursing home is a common place of death; however, little is known about the place of death with respect to the people living there. Was there a difference in the frequencies of the places of death of nursing home residents in an urban district and in the individual facilities before and during the COVID-19 pandemic? METHODS: Full survey of deaths by retrospective analysis of death registry data from the years 2018 to 2021. RESULTS: Over the four-year period 14,598 people died, with 3,288 (22.5%) being residents of 31 different nursing homes. Over the reference period before the pandemic (March 1, 2018 to December 31, 2019) 1,485 nursing home residents died: 620 (41.8%) in hospital, 863 (58.1%) in a nursing home. During the pandemic period (March 1, 2020 to December 31, 2021) 1,475 death were registered: 574 (38.9%) in hospital and 891 (60.4%) in a nursing home. The mean age over the reference period was 86.5 years (±8,6; median 88.4; 47.9 to 106.2), in the pandemic period it was 86.7 years (±8,5; median 87.9; 43.7 to 111.7). Before the pandemic 1,006 deaths (67.7%) occurred in females, during the pandemic it was 969 (65.7%). The relative risk (RR) as a measure for the increase in the probabilty for an "in-hospital" death during the pandemic period was 0.94. In different facilities, the number of deaths per bed during the reference and the pandemic period varied between 0.26 and 0.98, and the RR from 0.48 to 1.61. DISCUSSION: For all nursing home residents, the frequency of deaths was not increasing and no shift towards an "in-hospital" death was observed. Several nursing homes revealed substantial differences and opposing trends. The strength and the type of effects of facility-related circumstances remain unclear.

Differences in Resumption of Orthopedic Surgery According to Characteristics of Surgery during COVID-19 Pandemic: National Registry Data.

Background: Healthcare services have been restricted after the coronavirus disease 2019 (COVID-19) outbreak. With the pandemic still ongoing, the patterns of orthopedic surgery might have changed. The purpose of this study was to determine whether the reduced volumes of orthopedic surgery were recovered over time. Among the trauma and elective surgery, which accounted for most orthopedic surgical procedures, we also sought to elucidate whether the changes in the volumes of orthopedic surgery differed according to the type of surgery. Methods: The volumes of orthopedic surgery were analyzed using the Health Insurance Review and Assessment Service of Korea databases. The surgical procedure codes were categorized depending on the characteristics of the procedures. The actual volumes of surgery were compared with the expected volumes to elucidate the effect of COVID-19 on surgical volumes. The expected volumes of surgery were estimated using Poisson regression models. Results: The reducing effect of COVID-19 on the volumes of orthopedic surgery weakened as COVID-19 continued. Although the total volumes of orthopedic surgery decreased by 8.5%-10.1% in the first wave, those recovered to a 2.2%-2.8% decrease from the expected volumes during the second and third waves. Among the trauma and elective surgery, open reduction and internal fixation and cruciate ligament reconstruction decreased as COVID-19 continued, while total knee arthroplasty recovered. However, the volumes of hemiarthroplasty of the hip did not decrease through the year. Conclusions: The number of orthopedic surgeries, which had decreased due to COVID-19, tended to recover over time, although the pandemic was still ongoing. However, the degree of resumption differed according to the characteristics of surgery. The findings of our study will be helpful to estimate the burden of orthopedic surgery in the era of persistent COVID-19.

Patterns of use of emergency and oral contraceptives from an online service in the United Kingdom during the COVID-19 pandemic: A quantitative study of routinely collected data.

OBJECTIVES: Our study aimed to describe users of a free online contraception service, compare online emergency contraceptive pill (ECP) users with online oral contraceptive (OC) users, and describe patterns of use of online ECP and OC over time, including transition from ECP to more effective forms of contraception. STUDY DESIGN: Analysis of routinely collected, anonymized data from a large, publicly funded, online contraceptive service in the United Kingdom from April 1, 2019 to October 31, 2021. RESULTS: The online service provided 77,447 prescriptions during the study period. About 84% for OC and 16% for ECP, of which 89% were ulipristal acetate. ECP users were younger, lived in more deprived areas, and were less likely to be of white ethnicity than OC users. About 53% ordered OC only, but 37% ordered both ECP and OC. Among those prescribed both OC and ECP (n = 1306), 40% had one method as dominant, 25% appeared to move from one method to the other (11% ECP to OC, 14% OC to ECP), and 35% continued to use both methods. CONCLUSIONS: Online services are accessible to diverse young populations. While the majority of users order OC only, our study suggests that where there is free, online access to both OC and ECP, and those ordering ECP are always offered free OC, transition to more effective ongoing forms of contraception is uncommon. Further research is needed to understand whether online access to ECP increases its attractiveness and reduces likelihood of transition to OC. IMPLICATIONS: This study demonstrates that free, online contraceptive services are accessible to ethnically and socioeconomically diverse users. It identifies a subgroup of contraceptive users who combine use of OC and ECPs over time, and suggests that improved access to ECP may alter contraceptive choices.

Inequalities in children's mental health care: analysis of routinely collected data on prescribing and referrals to secondary care.

BACKGROUND: One in eight children in the United Kingdom are estimated to have a mental health condition, and many do not receive support or treatment. The COVID-19 pandemic has negatively impacted mental health and disrupted the delivery of care. Prevalence of poor mental health is not evenly distributed across age groups, by sex or socioeconomic groups. Equity in access to mental health care is a policy priority but detailed socio-demographic trends are relatively under-researched. METHODS: We analysed records for all mental health prescriptions and referrals to specialist mental health outpatient care between the years of 2015 and 2021 for children aged 2 to 17 years in a single NHS Scotland health board region. We analysed trends in prescribing, referrals, and acceptance to out-patient treatment over time, and measured differences in treatment and service use rates by age, sex, and area deprivation. RESULTS: We identified 18,732 children with 178,657 mental health prescriptions and 21,874 referrals to specialist outpatient care. Prescriptions increased by 59% over the study period. Boys received double the prescriptions of girls and the rate of prescribing in the most deprived areas was double that in the least deprived. Mean age at first mental health prescription was almost 1 year younger in the most deprived areas than in the least. Referrals increased 9% overall. Initially, boys and girls both had an annual referral rate of 2.7 per 1000, but this fell 6% for boys and rose 25% for girls. Referral rate for the youngest decreased 67% but increased 21% for the oldest. The proportion of rejected referrals increased steeply since 2020 from 17 to 30%. The proportion of accepted referrals that were for girls rose to 62% and the mean age increased 1.5 years. CONCLUSIONS: The large increase in mental health prescribing and changes in referrals to specialist outpatient care aligns with emerging evidence of increasing poor mental health, particularly since the start of the COVID-19 pandemic. The static size of the population accepted for specialist treatment amid greater demand, and the changing demographics of those accepted, indicate clinical prioritisation and unmet need. Persistent inequities in mental health prescribing and referrals require urgent action.

Patients with type 1 and type 2 diabetes hospitalized with COVID-19 in comparison with influenza: mortality and cardiorenal complications assessed by nationwide Swedish registry data.

BACKGROUND: The risk of severe coronavirus disease 2019 (COVID-19) is increased in people with diabetes, but effects of diabetes type and other risk factors remain incompletely characterized. We studied this in a Swedish cohort of hospitalized patients with type 1 and type 2 diabetes (T1D and T2D), also including comparisons with influenza epidemics of recent years. METHODS: Nationwide healthcare registries were used to identify patients. A total of 11,005 adult patients with diabetes (T1D, n = 373; T2D, n = 10,632) were hospitalized due to COVID-19 from January 1, 2020 to September 1, 2021. Moreover, 5111 patients with diabetes (304 T1D, 4807 T2D) were hospitalized due to influenza from January 1, 2015 to December 31, 2019. Main outcomes were death within 28 days after admission and new hospitalizations for heart failure (HF), chronic kidney disease (CKD), cardiorenal disease (CRD; composite of HF and CKD), myocardial infarction (MI) and stroke during 1 year of follow-up. RESULTS: Number of deaths and CRD events were 2025 and 442 with COVID-19 and 259 and 525 with influenza, respectively. Age- and sex-adjusted Cox regression models in COVID-19 showed higher risk of death and HF in T1D vs. T2D, hazard ratio (HR) 1.77 (95% confidence interval 1.41-2.22) and 2.57 (1.31-5.05). With influenza, T1D was associated with higher risk of death compared with T2D, HR 1.80 (1.26-2.57). Older age and previous CRD were associated with higher risks of death and hospitalization for CRD. After adjustment for prior comorbidities, mortality differences were still significant, but there were no significant differences in cardiovascular and renal outcomes. COVID-19 relative to influenza was associated with higher risk of death in both T1D and T2D, HR 2.44 (1.60-3.72) and 2.81 (2.59-3.06), respectively. CONCLUSIONS: In Sweden, patients with T1D as compared to T2D had a higher age- and sex-adjusted risk of death within 28 days and HF within one year after COVID-19 hospitalization, whereas the risks of other non-fatal cardiovascular and renal disease events were similar. Patients with T1D as well as T2D have a greater mortality rate when hospitalized due to COVID-19 compared to influenza, underscoring the importance of vaccination and other preventive measures against COVID-19 for diabetes patients.

Inaccurate recording of routinely collected data items influences identification of COVID-19 patients.

BACKGROUND: During the Coronavirus disease 2019 (COVID-19) pandemic it became apparent that it is difficult to extract standardized Electronic Health Record (EHR) data for secondary purposes like public health decision-making. Accurate recording of, for example, standardized diagnosis codes and test results is required to identify all COVID-19 patients. This study aimed to investigate if specific combinations of routinely collected data items for COVID-19 can be used to identify an accurate set of intensive care unit (ICU)-admitted COVID-19 patients. METHODS: The following routinely collected EHR data items to identify COVID-19 patients were evaluated: positive reverse transcription polymerase chain reaction (RT-PCR) test results; problem list codes for COVID-19 registered by healthcare professionals and COVID-19 infection labels. COVID-19 codes registered by clinical coders retrospectively after discharge were also evaluated. A gold standard dataset was created by evaluating two datasets of suspected and confirmed COVID-19-patients admitted to the ICU at a Dutch university hospital between February 2020 and December 2020, of which one set was manually maintained by intensivists and one set was extracted from the EHR by a research data management department. Patients were labeled 'COVID-19' if their EHR record showed diagnosing COVID-19 during or right before an ICU-admission. Patients were labeled 'non-COVID-19' if the record indicated no COVID-19, exclusion or only suspicion during or right before an ICU-admission or if COVID-19 was diagnosed and cured during non-ICU episodes of the hospitalization in which an ICU-admission took place. Performance was determined for 37 queries including real-time and retrospective data items. We used the F1 score, which is the harmonic mean between precision and recall. The gold standard dataset was split into one subset including admissions between February and April and one subset including admissions between May and December to determine accuracy differences. RESULTS: The total dataset consisted of 402 patients: 196 'COVID-19' and 206 'non-COVID-19' patients. F1 scores of search queries including EHR data items that can be extracted real-time ranged between 0.68 and 0.97 and for search queries including the data item that was retrospectively registered by clinical coders F1 scores ranged between 0.73 and 0.99. F1 scores showed no clear pattern in variability between the two time periods. CONCLUSIONS: Our study showed that one cannot rely on individual routinely collected data items such as coded COVID-19 on problem lists to identify all COVID-19 patients. If information is not required real-time, medical coding from clinical coders is most reliable. Researchers should be transparent about their methods used to extract data. To maximize the ability to completely identify all COVID-19 cases alerts for inconsistent data and policies for standardized data capture could enable reliable data reuse.

Association between covid-19 vaccination, SARS-CoV-2 infection, and risk of immune mediated neurological events: population based cohort and self-controlled case series analysis.

OBJECTIVE: To study the association between covid-19 vaccines, SARS-CoV-2 infection, and risk of immune mediated neurological events. DESIGN: Population based historical rate comparison study and self-controlled case series analysis. SETTING: Primary care records from the United Kingdom, and primary care records from Spain linked to hospital data. PARTICIPANTS: 8 330 497 people who received at least one dose of covid-19 vaccines ChAdOx1 nCoV-19, BNT162b2, mRNA-1273, or Ad.26.COV2.S between the rollout of the vaccination campaigns and end of data availability (UK: 9 May 2021; Spain: 30 June 2021). The study sample also comprised a cohort of 735 870 unvaccinated individuals with a first positive reverse transcription polymerase chain reaction test result for SARS-CoV-2 from 1 September 2020, and 14 330 080 participants from the general population. MAIN OUTCOME MEASURES: Outcomes were incidence of Bell's palsy, encephalomyelitis, Guillain-Barré syndrome, and transverse myelitis. Incidence rates were estimated in the 21 days after the first vaccine dose, 90 days after a positive test result for SARS-CoV-2, and between 2017 and 2019 for background rates in the general population cohort. Indirectly standardised incidence ratios were estimated. Adjusted incidence rate ratios were estimated from the self-controlled case series. RESULTS: The study included 4 376 535 people who received ChAdOx1 nCoV-19, 3 588 318 who received BNT162b2, 244 913 who received mRNA-1273, and 120 731 who received Ad26.CoV.2; 735 870 people with SARS-CoV-2 infection; and 14 330 080 people from the general population. Overall, post-vaccine rates were consistent with expected (background) rates for Bell's palsy, encephalomyelitis, and Guillain-Barré syndrome. Self-controlled case series was conducted only for Bell's palsy, given limited statistical power, but with no safety signal seen for those vaccinated. Rates were, however, higher than expected after SARS-CoV-2 infection. For example, in the data from the UK, the standardised incidence ratio for Bell's palsy was 1.33 (1.02 to 1.74), for encephalomyelitis was 6.89 (3.82 to 12.44), and for Guillain-Barré syndrome was 3.53 (1.83 to 6.77). Transverse myelitis was rare (<5 events in all vaccinated cohorts) and could not be analysed. CONCLUSIONS: No safety signal was observed between covid-19 vaccines and the immune mediated neurological events of Bell's palsy, encephalomyelitis, Guillain-Barré syndrome, and transverse myelitis. An increased risk of Bell's palsy, encephalomyelitis, and Guillain-Barré syndrome was, however, observed for people with SARS-CoV-2 infection.

Uptake of infant and preschool immunisations in Scotland and England during the COVID-19 pandemic: An observational study of routinely collected data.

BACKGROUND: In 2020, the SARS-CoV-2 (COVID-19) pandemic and lockdown control measures threatened to disrupt routine childhood immunisation programmes with early reports suggesting uptake would fall. In response, public health bodies in Scotland and England collected national data for childhood immunisations on a weekly or monthly basis to allow for rapid analysis of trends. The aim of this study was to use these data to assess the impact of different phases of the pandemic on infant and preschool immunisation uptake rates. METHODS AND FINDINGS: We conducted an observational study using routinely collected data for the year prior to the pandemic (2019) and immediately before (22 January to March 2020), during (23 March to 26 July), and after (27 July to 4 October) the first UK "lockdown". Data were obtained for Scotland from the Public Health Scotland "COVID19 wider impacts on the health care system" dashboard and for England from ImmForm. Five vaccinations delivered at different ages were evaluated; 3 doses of "6-in-1" diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B vaccine (DTaP/IPV/Hib/HepB) and 2 doses of measles, mumps, and rubella (MMR) vaccine. This represented 439,754 invitations to be vaccinated in Scotland and 4.1 million for England. Uptake during the 2020 periods was compared to the previous year (2019) using binary logistic regression analysis. For Scotland, uptake within 4 weeks of a child becoming eligible by age was analysed along with geographical region and indices of deprivation. For Scotland and England, we assessed whether immunisations were up-to-date at approximately 6 months (all doses 6-in-1) and 16 to 18 months (first MMR) of age. We found that uptake within 4 weeks of eligibility in Scotland for all the 5 vaccines was higher during lockdown than in 2019. Differences ranged from 1.3% for first dose 6-in-1 vaccine (95.3 versus 94%, odds ratio [OR] compared to 2019 1.28, 95% confidence intervals [CIs] 1.18 to 1.39) to 14.3% for second MMR dose (66.1 versus 51.8%, OR compared to 2019 1.8, 95% CI 1.74 to 1.87). Significant increases in uptake were seen across all deprivation levels. In England, fewer children due to receive their immunisations during the lockdown period were up to date at 6 months (6-in-1) or 18 months (first dose MMR). The fall in percentage uptake ranged from 0.5% for first 6-in-1 (95.8 versus 96.3%, OR compared to 2019 0.89, 95% CI 0.86- to 0.91) to 2.1% for third 6-in-1 (86.6 versus 88.7%, OR compared to 2019 0.82, 95% CI 0.81 to 0.83). The use of routinely collected data used in this study was a limiting factor as detailed information on potential confounding factors were not available and we were unable to eliminate the possibility of seasonal trends in immunisation uptake. CONCLUSIONS: In this study, we observed that the national lockdown in Scotland was associated with an increase in timely childhood immunisation uptake; however, in England, uptake fell slightly. Reasons for the improved uptake in Scotland may include active measures taken to promote immunisation at local and national levels during this period and should be explored further. Promoting immunisation uptake and addressing potential vaccine hesitancy is particularly important given the ongoing pandemic and COVID-19 vaccination campaigns.

Was the risk of death among the population of teachers and other school workers in England and Wales due to COVID-19 and all causes higher than other occupations during the pandemic in 2020? An ecological study using routinely collected data on deaths from the Office for National Statistics.

OBJECTIVES: To estimate occupation risk from COVID-19 among teachers and others working in schools using publicly available data on mortality in England and Wales. DESIGN: Analysis of national death registration data from the Office for National Statistics. SETTING: England and Wales, 8 March-28 December 2020, during the COVID-19 pandemic. PARTICIPANTS: The total working age population in England and Wales plus those still working aged over 65 years. PRIMARY AND SECONDARY OUTCOMES: Death with COVID-19 as a primary outcome and death from all causes as a secondary outcome. RESULTS: Across occupational groups, there was a strong correlation between COVID-19 mortality and both non-COVID-19 and all-cause mortality. The absolute mortality rates for deaths with COVID-19 were low among those working in schools (from 10 per 100 000 in female primary school teachers to 39 per 100 000 male secondary school teachers) relative to many other occupations (range: 9-50 per 100 000 in women; 10-143 per 100 000 in men). There was weak evidence that secondary school teachers had slightly higher risks of dying with COVID-19 compared with the average for all working-aged people, but stronger evidence of a higher risk compared with the average for all professionals; primary school teachers had a lower risk. All-cause mortality was also higher among all teachers compared with all professionals. Teaching and lunchtime assistants were not at higher risk of death from COVID-19 compared with all working-aged people. CONCLUSION: There was weak evidence that COVID-19 mortality risk for secondary school teachers was above expectation, but in general school staff had COVID-19 mortality risks which were proportionate to their non-COVID-19 mortality risk.

United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers (UK-REACH): a retrospective cohort study using linked routinely collected data, study protocol.

INTRODUCTION: COVID-19 has spread rapidly worldwide, causing significant morbidity and mortality. People from ethnic minorities, particularly those working in healthcare settings, have been disproportionately affected. Current evidence of the association between ethnicity and COVID-19 outcomes in people working in healthcare settings is insufficient to inform plans to address health inequalities. METHODS AND ANALYSIS: This study combines anonymised human resource databases with professional registration and National Health Service data sets to assess associations between ethnicity and COVID-19 diagnosis, hospitalisation and death in healthcare workers in the UK. Adverse COVID-19 outcomes will be assessed between 1 February 2020 (date following first confirmed COVID-19 case in UK) and study end date (31 January 2021), allowing 1-year of follow-up. Planned analyses include multivariable Poisson, logistic and flexible parametric time-to-event regression within each country, adjusting for core predictors, followed by meta-analysis of country-specific results to produce combined effect estimates for the UK. Mediation analysis methods will be explored to examine the direct, indirect and mediated interactive effects between ethnicity, occupational group and COVID-19 outcomes. ETHICS AND DISSEMINATION: Ethical approval for the UK-REACH programme has been obtained via the expedited HRA COVID-19 processes (REC ref: 20/HRA/4718, IRAS ID: 288316). Research information will be anonymised via the Secure Anonymised Information Linkage Databank before release to researchers. Study results will be submitted for publication in an open access peer-reviewed journal and made available on our dedicated website (https://uk-reach.org/). TRIAL REGISTRATION NUMBER: ISRCTN11811602.

Time for Inclusion of Racial and Gender Discrimination in Routine Clinical Assessment.

Recently, there has been an increasing amount of scientific interest towards the broad theme of racial inequalities and their impact on human health, specifically exploring how ethnic discrimination affects the wellness of black people and the COVID-19 pandemic. Some of these conditions of inequity also affect black children. Discrimination and racism should be routinely considered as causative agents or triggers of disease and routinely included in clinical examination, during history collection and evaluation of vital signs. This will benefit child and family health, worldwide. We shared our recent experience by reporting a case of a 13-year-old black girl who came to Italy from Niger about 3 years earlier through the traumatizing migratory journey. She was evaluated in the Pediatric Emergency Department (PED) for sleepiness that had progressively worsened during the last days. We describe the case and how it was handled differently by pediatricians and pediatric trainees with equally different personal and professional backgrounds.We also report the preliminary results of a national survey aimed to assess discrimination and inequalities in Italian Paediatric Residency Schools. Medical ability has been allowing us to respond rapidly to a novel virus in order to save lives. The expertise of doctors and researchers must be used to evaluate this hidden crisis as well, to address racism and injustice and to protect vulnerable people from harm. Our case showed us how it is essential including racial and gender discrimination in a diagnostic process.

An evaluation of advance care planning during the COVID-19 pandemic: a retrospective review of patient involvement in decision making using routinely collected data from digital ReSPECT records.

OBJECTIVE: To review advance care planning (ACP) practice during the COVID-19 pandemic, evaluating the number of plans created, patient participation, cardiopulmonary resuscitation recommendations and variation between different population groups. DESIGN: A retrospective analysis and comparison of routinely collected data from electronic recommended summary plan for emergency care and treatment (ReSPECT) records documented in April 2020 and January to December 2019. SETTING/PARTICIPANTS: Electronic ReSPECT documents completed for adult patients at a large, acute hospital trust in the UK. RESULTS: The number of plans created per 1,000 admissions in April 2020 was 333.0% higher than in 2019. A greater proportion of plans created during April 2020 were discussed with the patient and the proportion containing a 'for cardiopulmonary resuscitation' recommendation was higher across all population groups. A greater proportion of plans were created for younger adults and Black and minority ethnic groups during the pandemic. CONCLUSION: Increased ACP during a crisis can be achieved alongside increased patient participation in decision making. A tool such as ReSPECT that supports recommendations for, as well as limitations on, treatment may have enabled the expansion of ACP observed.