Population level impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in the people with covid-19 in England: a national analysis using a stepped wedge design

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.

Development and assessment of a machine learning tool for predicting emergency admission in Scotland

Avoiding emergency hospital admission (EA) is advantageous to individual health and the healthcare system. We develop a statistical model estimating risk of EA for most of the Scottish population (>4.8M individuals) using electronic health records, such as hospital episodes and prescribing activity. We demonstrate good predictive accuracy (AUROC 0.80), calibration and temporal stability. We find strong prediction of respiratory and metabolic EA, show a substantial risk contribution from socioeconomic decile, and highlight an important problem in model updating. Our work constitutes a rare example of a population-scale machine learning score to be deployed in a healthcare setting.

Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study

Background NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’. Objectives The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness. Design This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics. Methods A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision. Results Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time. Limitations Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time. Conclusions Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care. Future work Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.

Effectiveness of the Pfizer-BioNTech and Oxford-AstraZeneca vaccines on covid-19 related symptoms, hospital admissions, and mortality in older adults in England: test negative case-control study

Objective To estimate the real world effectiveness of the Pfizer-BioNTech BNT162b2 and Oxford-AstraZeneca ChAdOx1-S vaccines against confirmed covid-19 symptoms (including the UK variant of concern B.1.1.7), admissions to hospital, and deaths. Design Test negative case-control study. Setting Community testing for covid-19 in England. Participants 156 930 adults aged 70 years and older who reported symptoms of covid-19 between 8 December 2020 and 19 February 2021 and were successfully linked to vaccination data in the National Immunisation Management System. Interventions Vaccination with BNT162b2 or ChAdOx1-S. Main outcome measures Primary outcomes were polymerase chain reaction confirmed symptomatic SARS-CoV-2 infections, admissions to hospital for covid-19, and deaths with covid-19. Results Participants aged 80 years and older vaccinated with BNT162b2 before 4 January 2021 had a higher odds of testing positive for covid-19 in the first nine days after vaccination (odds ratio up to 1.48, 95% confidence interval 1.23 to 1.77), indicating that those initially targeted had a higher underlying risk of infection. Vaccine effectiveness was therefore compared with the baseline post-vaccination period. Vaccine effects were noted 10 to 13 days after vaccination, reaching a vaccine effectiveness of 70% (95% confidence interval 59% to 78%), then plateauing. From 14 days after the second dose a vaccination effectiveness of 89% (85% to 93%) was found compared with the increased baseline risk. Participants aged 70 years and older vaccinated from 4 January (when ChAdOx1-S delivery commenced) had a similar underlying risk of covid-19 to unvaccinated individuals. With BNT162b2, vaccine effectiveness reached 61% (51% to 69%) from 28 to 34 days after vaccination, then plateaued. With ChAdOx1-S, effects were seen from 14 to 20 days after vaccination, reaching an effectiveness of 60% (41% to 73%) from 28 to 34 days, increasing to 73% (27% to 90%) from day 35 onwards. On top of the protection against symptomatic disease, a further 43% (33% to 52%) reduced risk of emergency hospital admission and 51% (37% to 62%) reduced risk of death was observed in those who had received one dose of BNT162b2. Participants who had received one dose of ChAdOx1-S had a further 37% (3% to 59%) reduced risk of emergency hospital admission. Follow-up was insufficient to assess the effect of ChAdOx1-S on mortality. Combined with the effect against symptomatic disease, a single dose of either vaccine was about 80% effective at preventing admission to hospital with covid-19 and a single dose of BNT162b2 was 85% effective at preventing death with covid-19. Conclusion Vaccination with either one dose of BNT162b2 or ChAdOx1-S was associated with a significant reduction in symptomatic covid-19 in older adults, and with further protection against severe disease. Both vaccines showed similar effects. Protection was maintained for the duration of follow-up (>6 weeks). A second dose of BNT162b2 was associated with further protection against symptomatic disease. A clear effect of the vaccines against the B.1.1.7 variant was found.

Sick day advice for people with diabetes

In this article Martha Stewart discusses how illness affects diabetes management and outlines the ‘sick-day advice’ that should be shared with people living with type 1 and type 2 diabetes Intercurrent illness can cause glucose levels to rise in people with diabetes mellitus. These illnesses include the common cold, diarrhoea and vomiting, urinary tract infections and COVID-19. If diabetes is not managed well during illness it can escalate and result in more serious conditions, such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS), which would require emergency hospital admission. This article discusses how illness affects diabetes management and outlines the ‘sick-day advice’ that should be shared with people living with type 1 and type 2 diabetes.

Sociodemographic profile of pediatric poisoning cases

Background: Poisoning is one of the commonest cause of emergency hospital admission in children. The accidental poisoning is seen more commonly in toddlers and intentional poisoning is seen in adolescents. Rapid globalization and increased stress has increased the risk of suicidal poisoning. The accidental poisoning can be reduced by proper education to parents and by keeping poisonous substances out of reach of the child.Methods: The study was carried out over 18 months. Sociodemographic profile of pediatric cases was studied in department of pediatrics at Rajarajeswari medical college and hospital. Descriptive study analysis was done.Results: During 18 month study period, 34 cases were analysed. The incidence was found to be 1.64%. Male:female ratio was found to be 1:1.6. Majority belonged to upper lower class and majority were from urban class.Conclusions: The importance childhood poisoning with its association with socio-demographic factors were studied and intervention were done.

P0324SODIUM ZIRCONIUM CYCLOSILICATE TO PREVENT HYPERKALAEMIA IF HAEMODIALYSIS IS POSTPONED DUE TO VASCULAR ACCESS COMPLICATIONS: EXPERIENCE FROM CLINICAL PRACTICE

Background and Aims Vascular access is a fundamental aspect of haemodialysis (HD) treatment. Vascular access may be compromised due to central venous catheter (CVC) thrombosis, arterio-venous fistula (AVF) or graft (AVG) stenosis, infections or perioperative complications that require urgent resolution or the formation of alternative emergency or definitive access. Sodium zirconium cyclosilicate (SZC) (Lokelma®) is a new oral potassium binder. We offer an insight into SZC treatment to prevent hyperkalaemia in patients where HD is postponed due to vascular access complications. Method Adult prevalent HD patients were included for analysis. Each patient was unable to receive their full scheduled HD treatment due to a vascular access complication. SZC was prescribed on the day HD was not possible (D1) until the vascular access issue was resolved and HD could recommence. The primary efficacy measures were the prevention of increases in serum potassium (sK+), the safe postponement of HD and the avoidance of emergency hospital admission. Results Four patients receiving thrice-weekly HD (mean age 69 years, all male) received SZC for a mean duration of 3.5 days (min 2 days, max 6 days). No patients were admitted during these acute episodes. The mean pre-dialysis sK+ on D1 was 6.0mmol/L (K1). No post-dialysis sK+ values were obtained on D1 because HD was not possible or cut-short (Table 1). For patients 2 and 3, one and 10 HD treatments preceded the next sK+ (K2) respectively. sK+ reduced from 5.8mmol/L (K1) to 4.8mmol/L (K2) for patients 1 and 4 (Table 1). No statistical analyses were undertaken due to the low patient numbers. HD was delayed beyond the scheduled treatment date for 3 of the 4 patients, with a mean delay of 1.75 days (min 0 days, max 3 days) (Table 2). There was no delay between HD treatments for patient 2, who only received 1 hour HD treatment on D1. The last full HD treatment for patient 2 was 3 days prior to D1. A gap between SZC initiation (D1) and the next HD treatment was seen for all four patients, with a mean gap of 2 days (min 1 day, max 3 days) (Table 2). Conclusion Sodium zirconium cyclosilicate can be used to successfully reduce, or avoid an increase in sK+ in mild to moderate hyperkalaemia, avoid emergency hospital admission and allow HD to be postponed for a valuable short period until HD vascular access can be re-established.

Impact of emergency hospital admissions on patterns of primary care prescribing: a retrospective cohort analysis of electronic records in England

BackgroundLittle is known about the impact of hospitalisation on prescribing in UK clinical practice.AimTo investigate whether an emergency hospital admission drives increases in polypharmacy and potentially inappropriate prescriptions (PIPs).Design and settingA retrospective cohort analysis set in primary and secondary care in England.MethodChanges in number of prescriptions and PIPs following an emergency hospital admission in 2014 (at admission and 4 weeks post-discharge), and 6 months post-discharge were calculated among 37 761 adult patients. Regression models were used to investigate changes in prescribing following an admission.ResultsEmergency attendees surviving 6 months (N = 32 657) had a mean of 4.4 (standard deviation [SD] = 4.6) prescriptions before admission, and a mean of 4.7 (SD = 4.7; P<0.001) 4 weeks after discharge. Small increases (<0.5) in the number of prescriptions at 4 weeks were observed across most hospital specialties, except for surgery (−0.02; SD = 0.65) and cardiology (2.1; SD = 2.6). The amount of PIPs increased after hospitalisation; 4.0% of patients had ≥1 PIP immediately before pre-admission, increasing to 8.0% 4 weeks post-discharge. Across hospital specialties, increases in the proportion of patients with a PIP ranged from 2.1% in obstetrics and gynaecology to 8.0% in cardiology. Patients were, on average, prescribed fewer medicines at 6 months compared with 4 weeks post-discharge (mean = 4.1; SD = 4.6; P<0.001). PIPs decreased to 5.4% (n = 1751) of patients.ConclusionPerceptions that hospitalisation is a consistent factor driving rises in polypharmacy are unfounded. Increases in prescribing post-hospitalisation reflect appropriate clinical response to acute illness, whereas decreases are more likely in patients who are multimorbid, reflecting a focus on deprescribing and medicines optimisation in these individuals. Increases in PIPs remain a concern.