Implementation of corticosteroids in treatment of COVID-19 in the ISARIC WHO Clinical Characterisation Protocol UK: prospective, cohort study.

BACKGROUND: Dexamethasone was the first intervention proven to reduce mortality in patients with COVID-19 being treated in hospital. We aimed to evaluate the adoption of corticosteroids in the treatment of COVID-19 in the UK after the RECOVERY trial publication on June 16, 2020, and to identify discrepancies in care. METHODS: We did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260. FINDINGS: Between June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 [86·6%] of 12 909 vs 36 415 [72·4%] of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 [95% CI 0·70-0·89], p=0·0001, for 70-79 years; 0·52 [0·46-0·58], p<0·0001, for >80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75-80% in January, 2021. INTERPRETATION: Implementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered. FUNDING: UK National Institute for Health Research and UK Medical Research Council.

GP-led adapted comprehensive geriatric assessment for frail older people: a multi-methods evaluation of the 'Living Well Assessment' quality improvement project in Scotland.

BACKGROUND: Evidence to support comprehensive geriatric assessment (CGA) in primary care for frail older people is limited. AIM: To evaluate a GP-led adapted CGA quality improvement project. DESIGN & SETTING: Multi-methods evaluation in a large practice in Midlothian in Scotland. METHOD: The intervention was conducted by 10 GPs in a practice of approximately 11 000 patients, initially in the patient's home, and then remotely (by telephone or video consultation) during the COVID-19 pandemic. Evaluation included a patient questionnaire, and qualitative interviews with GPs delivering the Living Well Assessment (LWA), analysed by thematic analysis. RESULTS: A total of 165/220 (75%) patients responded to the survey, of which 86% reported a 'very good experience' of the LWA. The method of delivery did not significantly influence this although most (58%) stated a preference for face-to-face consultation. For the 31% who preferred remote LWA, most (23%) preferred telephone to video consultation (8%). Problems in remote consultations related to technical issues (video), poor vision (video), or deafness (telephone or video). GPs felt that home-based LWAs had real benefits but switching to remote during the pandemic had proven feasible. Concerns included potential increase in GP workload owing to the LWA and whether it was an efficient use of GPs' time. CONCLUSION: GP-led adapted CGA was feasible in a large practice, even during the pandemic, and highly valued by frail patients. Questions regarding efficient use of GPs' time, effectiveness in terms of important patient outcomes and impact, and cost-effectiveness, requires further investigation in a larger study.

The Prognostic and Discriminatory Utility of the Clinical Frailty Scale and Modified Frailty Index Compared to Age.

Background: There is no consensus on the optimal method for the assessment of frailty. We compared the prognostic utility of two approaches (modified Frailty Index [mFI], Clinical Frailty Scale [CFS]) in older adults (≥65 years) hospitalised with COVID-19 versus age. Methods: We used a test and validation cohort that enrolled participants hospitalised with COVID-19 between 27 February and 30 June 2020. Multivariable mixed-effects logistic modelling was undertaken, with 28-day mortality as the primary outcome. Nested models were compared between a base model, age and frailty assessments using likelihood ratio testing (LRT) and an area under the receiver operating curves (AUROC). Results: The primary cohort enrolled 998 participants from 13 centres. The median age was 80 (range:65-101), 453 (45%) were female, and 377 (37.8%) died within 28 days. The sample was replicated in a validation cohort of two additional centres (n = 672) with similar characteristics. In the primary cohort, both mFI and CFS were associated with mortality in the base models. There was improved precision when fitting CFS to the base model +mFI (LRT = 25.87, p < 0.001); however, there was no improvement when fitting mFI to the base model +CFS (LRT = 1.99, p = 0.16). AUROC suggested increased discrimination when fitting CFS compared to age (p = 0.02) and age +mFI (p = 0.03). In contrast, the mFI offered no improved discrimination in any comparison (p > 0.05). Similar findings were seen in the validation cohort. Conclusions: These observations suggest the CFS has superior prognostic value to mFI in predicting mortality following COVID-19. Our data do not support the use of the mFI as a tool to aid clinical decision-making and prognosis.

Foundation Level Barriers to the Widespread Adoption of Digital Solutions by Care Homes: Insights from Three Scottish Studies.

The care home sector has great potential to benefit from technological innovations and to be at the forefront of developing novel digital solutions to improve the experiences of care home residents, their families, and the staff caring for them. The COVID-19 pandemic exposed variability in digital capabilities and longstanding data challenges within the care home sector. Paradoxically, however, it also increased the use of digital tools and services to support residents and staff. There are, however, a number of barriers to sustained and widespread adoption of digital solutions by care homes. Here, the focus is on foundation-level barriers and the groundwork required to overcome them. Using data from three Scottish-based studies, foundation-level barriers to the adoption of digital tools and services faced by care homes are discussed. These main barriers are the need for robust basic internet connectivity; capabilities for digital data collection; access to data to inform and drive digital solutions; the need for trust in the use of resident data by commercial companies; and the danger that poorly coordinated strategies undermine efforts to build a care home data platform and the digital solutions it can support. Sustained and widespread adoption of digital solutions by care homes will require these foundation-level barriers to be addressed. Strong and stable data and digital foundations supported by sector-specific scaffolding are major prerequisites to the widespread adoption of digital solutions by care homes.

Foundation Level Barriers to the Widespread Adoption of Digital Solutions by Care Homes: Insights from Three Scottish Studies

The care home sector has great potential to benefit from technological innovations and to be at the forefront of developing novel digital solutions to improve the experiences of care home residents, their families, and the staff caring for them. The COVID-19 pandemic exposed variability in digital capabilities and longstanding data challenges within the care home sector. Paradoxically, however, it also increased the use of digital tools and services to support residents and staff. There are, however, a number of barriers to sustained and widespread adoption of digital solutions by care homes. Here, the focus is on foundation-level barriers and the groundwork required to overcome them. Using data from three Scottish-based studies, foundation-level barriers to the adoption of digital tools and services faced by care homes are discussed. These main barriers are the need for robust basic internet connectivity;capabilities for digital data collection;access to data to inform and drive digital solutions;the need for trust in the use of resident data by commercial companies;and the danger that poorly coordinated strategies undermine efforts to build a care home data platform and the digital solutions it can support. Sustained and widespread adoption of digital solutions by care homes will require these foundation-level barriers to be addressed. Strong and stable data and digital foundations supported by sector-specific scaffolding are major prerequisites to the widespread adoption of digital solutions by care homes.

Research with older people in a world with COVID-19: identification of current and future priorities, challenges and opportunities.

Older people are disproportionately affected by the COVID-19 pandemic, which has had a profound impact on research as well as clinical service delivery. This commentary identifies key challenges and opportunities in continuing to conduct research with and for older people, both during and after the current pandemic. It shares opinions from responders to an international survey, a range of academic authors and opinions from specialist societies. Priorities in COVID-19 research include its specific presentation in older people, consequences for physical, cognitive and psychological health, treatments and vaccines, rehabilitation, supporting care homes more effectively, the impact of social distancing, lockdown policies and system reconfiguration to provide best health and social care for older people. COVID-19 research needs to be inclusive, particularly involving older people living with frailty, cognitive impairment or multimorbidity, and those living in care homes. Non-COVID-19 related research for older people remains of critical importance and must not be neglected in the rush to study the pandemic. Profound changes are required in the way that we design and deliver research for older people in a world where movement and face-to-face contact are restricted, but we also highlight new opportunities such as the ability to collaborate more widely and to design and deliver research efficiently at scale and speed.