Assessing the Safety of Home Oximetry for Covid-19: A multi-site retrospective observational study

AbstractObjectivesTo determine the safety and effectiveness of home oximetry monitoring pathways safe for Covid-19 patients in the English NHSDesignThis was a retrospective, multi-site, observational study of home oximetry monitoring for patients with suspected or proven Covid-19SettingThis 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 topicThe Covid-19 pandemic has created a new and significant burden on health systems globally.Oxygen saturations have been found to be an important factor to stratify patient risk and guide treatment of Covid-19.Home oximetry programmes emerged during the early stages of the pandemic as an innovative means of monitoring patients with Covid-19 without admission to hospital.Section 2: What this study addsHome 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.Home 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.

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Assessing the safety of home oximetry for COVID-19: a multisite retrospective observational study

BMJ Open ◽

10.1136/bmjopen-2021-049235 ◽

2021 ◽

Vol 11 (9) ◽

pp. e049235

Author(s):

Jonathan Clarke ◽

Kelsey Flott ◽

Roberto Fernandez Crespo ◽

Hutan Ashrafian ◽

Gianluca Fontana ◽

...

Keyword(s):

Primary Care ◽

Observational Study ◽

Vulnerable Groups ◽

Care Services ◽

Primary Care Services ◽

National Implementation ◽

Primary Care Patients ◽

Discharge From Hospital ◽

English National Health ◽

Increases In Risk

ObjectivesTo determine the safety and effectiveness of home oximetry monitoring pathways for patients with COVID-19 in the English National Health Service.DesignRetrospective, multisite, 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 England across primary and secondary care settings.ParticipantsA total of 1338 participants were enrolled in a home oximetry programme across four pilot sites. Participants were excluded if primary care data and oxygen saturations at rest at enrolment were not available. Data from 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 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 (2.53–29.89)), compared with those enrolled in primary care. Patients enrolled after hospital discharge (OR 0.31 (0.15–0.68)) or emergency department presentation (OR 0.42 (0.20–0.89)) were significantly less likely to present to hospital than those enrolled in primary care.ConclusionsThis study finds that home oximetry monitoring can be a safe pathway for patients with COVID-19; 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.

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A primary care lifestyle programme suitable for socioeconomically vulnerable groups – an observational study

Scandinavian Journal of Primary Health Care ◽

10.1080/02813432.2016.1248628 ◽

2016 ◽

Vol 34 (4) ◽

pp. 352-359 ◽

Cited By ~ 2

Author(s):

Maria Waller ◽

Ann Blomstrand ◽

Tine Högberg ◽

Nashmil Ariai ◽

Jörgen Thorn ◽

...

Keyword(s):

Primary Care ◽

Observational Study ◽

Vulnerable Groups ◽

Lifestyle Programme

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Emergency care access to primary care records: an observational study

BMJ Health & Care Informatics ◽

10.1136/bmjhci-2020-100153 ◽

2020 ◽

Vol 27 (3) ◽

pp. e100153

Author(s):

Thomas Bowden ◽

David Lyell ◽

Enrico Coiera

Keyword(s):

Primary Care ◽

Observational Study ◽

Hospital Admission ◽

Emergency Care ◽

Patient Characteristics ◽

Care Access ◽

Process Outcomes ◽

Primary Care Record ◽

Access To Primary Care ◽

The Impact

ObjectiveTo measure lookup rates of externally held primary care records accessed in emergency care and identify patient characteristics, conditions and potential consequences associated with access.MeasuresRates of primary care record access and re-presentation to the emergency department (ED) within 30 days and hospital admission.DesignA retrospective observational study of 77 181 ED presentations over 4 years and 9 months, analysing 8184 index presentations in which patients’ primary care records were accessed from the ED. Data were compared with 17 449 randomly selected index control presentations. Analysis included propensity score matching for age and triage categories.Results6.3% of overall ED presentations triggered a lookup (rising to 8.3% in year 5); 83.1% of patients were only looked up once and 16.9% of patients looked up on multiple occasions. Lookup patients were on average 25 years older (z=−9.180, p<0.001, r=0.43). Patients with more urgent triage classifications had their records accessed more frequently (z=−36.47, p<0.001, r=0.23). Record access was associated with a significant but negligible increase in hospital admission (χ2 (1, n=13 120)=98.385, p<0.001, phi=0.087) and readmission within 30 days (χ2 (1, n=13 120)=86.288, p<0.001, phi=0.081).DiscussionEmergency care clinicians access primary care records more frequently for older patients or those in higher triage categories. Increased levels of inpatient admission and re-presentation within 30 days are likely linked to age and triage categories.ConclusionFurther studies should focus on the impact of record access on clinical and process outcomes and which record elements have the most utility to shape clinical decisions.

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The impact of opiate substitution treatment on mortality risk in drug addicts: a natural experiment study

Health Services and Delivery Research ◽

10.3310/hsdr07030 ◽

2019 ◽

Vol 7 (3) ◽

pp. 1-92 ◽

Cited By ~ 1

Author(s):

Colin D Steer ◽

John Macleod ◽

Kate Tilling ◽

Aaron G Lim ◽

John Marsden ◽

...

Keyword(s):

Primary Care ◽

Observational Study ◽

Mortality Risk ◽

Treatment Duration ◽

Hazard Ratio ◽

Substitution Treatment ◽

Opiate Substitution Treatment ◽

All Cause Mortality ◽

Prospective Longitudinal ◽

Cessation Of Treatment

Background Opiate substitution treatment (OST) is the main treatment for people addicted to heroin and other opioid drugs. However, there is limited information on how the delivery of this treatment affects mortality risk. Objectives To investigate the associations of mortality risk with periods during treatment and following cessation of treatment, medication type, co-prescription of other medication and dosing regimens during titration and detoxification. The trends with time of prescribed medication, dose and treatment duration were also explored. Design Prospective longitudinal observational study. Setting UK primary care between 1998 and 2014. Participants A total of 12,780 patients receiving methadone, buprenorphine or dihydrocodeine. Main outcome measures All-cause mortality relating to 657 deaths and drug-related poisoning relating to 113 deaths. Data sources Clinical Practice Research Datalink with linked information on cause of death from the Office for National Statistics. Results For both outcomes, the lowest mortality risk was observed after 4 weeks of treatment and the highest risk was observed in the first 4 weeks following cessation of treatment [e.g. for drug-related poisoning, incidence rate ratio (IRR) 8.15, 95% confidence interval (CI) 5.45 to 12.19]. There was evidence that the treatment period risks varied with OST medication. The largest difference in risk was for the first 4 weeks of treatment for both outcomes, with patients on buprenorphine being at lower risk than those on methadone (e.g. for drug-related poisoning, IRR 0.08, 95% CI 0.01 to 0.48). The co-prescription of benzodiazepines was associated with linearly increasing the risk of drug-related deaths by dose (IRR 2.02, 95% CI 1.66 to 2.47), whereas z-drugs (zolpidem, zopiclone and zaleplon) were associated with increased risk of both all-cause (IRR 1.83, 95% CI 1.59 to 2.12) and drug-related (IRR 3.31, 95% CI 2.45 to 4.47) mortality. There was weak evidence that higher initial and final doses were associated with increased all-cause mortality risk. In the first 4 weeks of treatment, the risk increased by 4% for each 5-mg increment in methadone dose (1-mg increase in buprenorphine) (hazard ratio 1.04, 95% CI 1.00 to 1.09). In the first 4 weeks after treatment ceased, a similar increment in final dose increased the risk by 3% (hazard ratio 1.03, 95% CI 0.99 to 1.07). There were too few deaths to evaluate the effects on drug-related poisoning. The proportion of OST patients receiving buprenorphine increased between 1998 and 2006. Median treatment duration was consistently shorter for buprenorphine than for methadone for each year studied (overall median duration of 48 and 106 days, respectively). Limitations As this was an observational study, the possibility remains of bias from unmeasured factors, which covariate adjustment and inverse probability weighting can eliminate only partially. Conclusions Using buprenorphine as an alternative to methadone may not reduce mortality overall despite resulting in lower IRRs from shorter treatment duration. Clinical guidance needs to consider strengthening warnings about the co-prescription of a range of drugs for OST patients. Future work Our analyses need to be replicated using other clinical data sets in the UK and in other countries. New interventions and trials are required to investigate improving the retention of OST patients in primary care. Funding The National Institute for Health Research Health Services and Delivery Research programme.

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All-cause mortality among patients treated with repurposed antivirals and antibiotics for COVID-19 in Mexico City: A Real-World Observational Study

10.1101/2020.10.13.20211797 ◽

2020 ◽

Author(s):

Javier Mancilla-Galindo ◽

Jorge Óscar García-Méndez ◽

Jessica Márquez-Sánchez ◽

Rodrigo Estefano Reyes-Casarrubias ◽

Eduardo Aguirre-Aguilar ◽

...

Keyword(s):

Clinical Trials ◽

General Population ◽

Observational Study ◽

Mexico City ◽

Mortality Risk ◽

Real World ◽

List Type ◽

Risk Of Death ◽

All Cause Mortality ◽

Critical Patients

ABSTRACTAimTo evaluate all-cause mortality risk in patients with laboratory-confirmed COVID-19 in Mexico City treated with repurposed antivirals and antibiotics.MethodsThis real-world retrospective cohort study contemplated 395,343 patients evaluated for suspected COVID-19 between February 24 and September 14, 2020 in 688 primary-to-tertiary medical units in Mexico City. Patients were included with a positive RT-PCR for SARS-CoV-2; those receiving unspecified antivirals, excluded; and antivirals prescribed in <30 patients, eliminated. Survival and mortality risks were determined for patients receiving antivirals, antibiotics, both, or none.Results136,855 patients were analyzed; mean age 44.2 (SD:16.8) years; 51.3% were men. 16.6% received antivirals (3%), antibiotics (10%), or both (3.6%). Antivirals studied were Oseltamivir (n=8414), Amantadine (n=319), Lopinavir-Ritonavir (n=100), Rimantadine (n=61), Zanamivir (n=39), and Acyclovir (n=36). Survival with antivirals (73.7%, p<0.0001) and antibiotics (85.8%, p<0.0001) was lower than no antiviral/antibiotic (93.6%). After multivariable adjustment, increased risk of death occurred with antivirals (HR=1.72, 95%CI:1.61-1.84) in ambulatory (HR=4.7, 95%CI:3.94-5.62) and non-critical (HR=2.03, 95%CI:1.86-2.21) patients. Oseltamivir increased mortality risk in the general population (HR=1.72, 95%CI:1.61-1.84), ambulatory (HR=4.79, 95%CI:4.01-5.75), non-critical (HR=2.05, 95%CI:1.88-2.23), and pregnancy (HR=8.35, 95%CI:1.77-39.30); as well as hospitalized (HR=1.13, 95%CI:1.01-1.26) and critical patients (HR:1.22, 95%CI:1.05-1.43) after propensity score-matching. Antibiotics were a risk factor in general population (HR=1.13, 95%CI:1.08-1.19) and pediatrics (HR=4.22, 95%CI:2.01-8.86), but a protective factor in hospitalized (HR=0.81, 95%CI:0.77-0.86) and critical patients (HR=0.67, 95%CI:0.63-0.72).ConclusionsNo significant benefit for repurposed antivirals was observed; oseltamivir was associated with increased mortality. Antibiotics increased mortality risk in the general population but may increase survival in hospitalized and critical patients.WHAT IS ALREADY KNOWNCurrent recommendations for using repurposed antivirals and antibiotics for COVID-19 are conflicting.Few antivirals (i.e. lopinavir-ritonavir) have been shown to provide no additional benefit for COVID-19 in clinical trials; other antivirals may be having widespread use in real-world settings without formal assessment in clinical trials.Real-world use of repurposed antivirals and antibiotics for COVID-19 in population-based studies have not been performed; important populations have been left largely understudied (ambulatory patients, pregnant women, and pediatrics).WHAT THIS STUDY ADDSThis is the first real-world observational study evaluating amantadine, rimantadine, zanamivir, and acyclovir for COVID-19; no registered studies to evaluate these drugs exist. Only one study has evaluated risk of death for oseltamivir. Lopinavir-ritonavir have been previously evaluated in clinical trials.Repurposed antivirals and antibiotics were commonly prescribed in 688 ambulatory units and hospitals of Mexico City despite unclear recommendations for their use out of clinical trials.Oseltamivir was associated with increased mortality risk; other repurposed antivirals (zanamivir, amantadine, rimantadine, and acyclovir) had no significant and consistent impact on mortality. Antibiotics were associated with increased mortality risk in the general population but may increase survival in hospitalized and critical patients.

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Overall and cause-specific hospitalisation and death after COVID-19 hospitalisation in England: cohort study in OpenSAFELY using linked primary care, secondary care and death registration data

10.1101/2021.07.16.21260628 ◽

2021 ◽

Author(s):

Krishnan Bhaskaran ◽

Christopher T Rentsch ◽

George Hickman ◽

William J Hulme ◽

Anna Schultze ◽

...

Keyword(s):

Primary Care ◽

General Population ◽

Hospital Admission ◽

Cox Regression ◽

Adverse Outcomes ◽

Hospital Data ◽

Post Discharge ◽

Initial Infection ◽

All Cause Mortality ◽

Population Controls

Background: There is concern about medium to long-term adverse outcomes following acute COVID-19, but little relevant evidence exists. We aimed to investigate whether risks of hospital admission and death, overall and by specific cause, are raised following discharge from a COVID-19 hospitalisation. Methods and Findings: Working on behalf of NHS-England, we used linked primary care and hospital data in OpenSAFELY to compare risks of hospital admission and death, overall and by specific cause, between people discharged from COVID-19 hospitalisation (February-December 2020), and (i) demographically-matched controls from the 2019 general population; (ii) people discharged from influenza hospitalisation in 2017-19. We used Cox regression adjusted for personal and clinical characteristics. 24,673 post-discharge COVID-19 patients, 123,362 general population controls, and 16,058 influenza controls were followed for ≤315 days. Overall risk of hospitalisation or death (30968 events) was higher in the COVID-19 group than general population controls (adjusted-HR 2.23, 2.14-2.31) but similar to the influenza group (adjusted-HR 0.94, 0.91-0.98). All-cause mortality (7439 events) was highest in the COVID-19 group (adjusted-HR 4.97, 4.58-5.40 vs general population controls and 1.73, 1.60-1.87 vs influenza controls). Risks for cause-specific outcomes were higher in COVID-19 survivors than general population controls, and largely comparable between COVID-19 and influenza patients. However, COVID-19 patients were more likely than influenza patients to be readmitted/die due to their initial infection/other lower respiratory tract infection (adjusted-HR 1.37, 1.22-1.54), and to experience mental health or cognitive-related admission/death (adjusted-HR 1.36, 1.01-2.83); in particular, COVID-19 survivors with pre-existing dementia had higher risk of dementia death. One limitation of our study is that reasons for hospitalisation/death may have been misclassified in some cases due to inconsistent use of codes. Conclusions: People discharged from a COVID-19 hospital admission had markedly higher risks for rehospitalisation and death than the general population, suggesting a substantial extra burden on healthcare. Most risks were similar to those observed after influenza hospitalisations; but COVID-19 patients had higher risks of all-cause mortality, readmissions/death due to the initial infection, and dementia death, highlighting the importance of post-discharge monitoring.

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