Developing useful early warning and prognostic scores for COVID-19

Abstract Early recognition of high-risk or deteriorating patients with COVID-19 allows timely treatment escalation and optimises allocation of scarce resources across overstretched healthcare systems. Since the late 1990s, physiological scoring systems have been used in hospital settings to provide an objective signal of clinical deterioration prompting urgent clinical review. Several early warning scores (EWS) accurately predict the need for intensive care unit admission and survival in hospitalised patients with sepsis and other acute illnesses, and their routine use is now recommended in secondary care settings in high and low income countries alike. However, there are widespread concerns that existing EWS, which place a premium on the cardiovascular instability seen in severe sepsis, may fail to identify the deteriorating COVID-19 patient. Dozens of research groups have now assessed the predictive value of existing EWS in hospitalised adults with COVID-19, and used sophisticated statistical methods to develop novel early warning and prognostic scores incorporating vital signs, laboratory tests and imaging results. However, many of these novel scores are at high risk of bias and few have been adopted in routine clinical practice. In this education and learning article, we will discuss key pitfalls of existing prognostic and EWS in hospitalised adults with COVID-19; outline promising novel scores for this patient group; and describe the ideal properties of scoring systems suitable for use in low and middle income settings

Investigating the mechanism of impact of the quality premium initiative on antibiotic prescribing in primary care practices in England: a study protocol

Introduction The persistent development and spread of resistance to antibiotics remains an important public health concern in the UK and globally. About 74% of antibiotics prescribed in England in 2016 was in primary care. The Quality Premium (QP) initiative that rewards Clinical Commissioning Groups (CCGs) financially based on the quality of specific health services commissioned is one of the National Health Service (NHS) England interventions to reduce antimicrobial resistance through reduced prescribing. Emerging evidence suggests a reduction in antibiotic prescribing in primary care practices in the UK following QP initiative. This study aims to investigate the mechanism of impact of this high-cost health-system level intervention on antibiotic prescribing in primary care practices in England. Methods and analysis The study will constitute secondary analyses of antibiotic prescribing data for almost all primary care practices in England from the NHS England Antibiotic Quality Premium Monitoring Dashboard and OpenPrescribing covering the period 2013 to 2018. The primary outcome is the number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed monthly in each practice or CCG. We will first conduct an interrupted time series using Ordinary Least Square regression method to examine whether antibiotic prescribing rate in England has changed over time, and how such changes, if any, are associated with QP implementation. Single and sequential multiple-mediator models using a unified approach for the natural direct and indirect effects will be conducted to investigate the relationship between QP initiative, the potential mediators and antibiotic prescribing rate with adjustment for practice and CCG characteristics. Ethics and dissemination This study will use secondary data that are anonymised and obtained from studies that have either undergone ethical review or generated data from routine collection systems. Multiple channels will be used in disseminating the findings from this study to academic and non-academic audiences. Strengths and Limitations of this study • This study will be the first to evaluate the mechanism of the impact of a financial incentive initiative involving Clinical Commissioning Groups to improve antibiotic prescribing in primary care practices in England. • The investigation of multiple mediators in this study will help to identify the contributions of multiple strategies in translating the effects of QP while unpacking the extent of the effect of specific mediators. • Due to the limited data on practice-level interventions or strategies that might potentially mediate the effect of the QP on antibiotic prescribing, we will not be able to extensively investigate the mechanism of QP impact at the practice level. • Nevertheless, extensive investigations will be conducted at CCG level where the Quality Premium initiative is implemented, and rewards paid out

Antibiotic repeat prescriptions: are patients not re-filling them properly?

Objective: This study aimed to explore patients’ utilization of repeat prescriptions for antibiotics indicated in upper respiratory tract infections (URTI). An emphasis was placed on whether the current system of repeat prescriptions contributes to patients self-diagnosing infections and if so, identify the common reasons for this. Methods: This is a prospective study of self-reported use of repeat antibiotic prescriptions by pharmacy consumers presenting with repeat prescriptions for antibiotics commonly indicated in URTIs. Data were collected via self-completed surveys in Perth metropolitan pharmacies. Results: A total of 123 respondents participated in this study from 19 Perth metropolitan pharmacies. Of the respondents, approximately a third of them (33.9%) presented to the pharmacy to fill their antibiotic repeat prescription one month or more from the time the original prescription was written (i.e. time when original diagnosis was made by a doctor). Over two thirds of respondents indicated to not have consulted their doctor prior to presenting to the pharmacy to have their antibiotic repeat prescription dispensed (i.e. 68.3%). The most common reasons for this were that their ‘doctor had told them to take the second course’ (38%), followed by potential self-diagnosis (29%), i.e. ‘they had the same symptoms as the last time they took the antibiotics’. Approximately one third (33.1%) of respondents indicated they ‘were not told what the repeat prescription was needed for’ when they were originally prescribed the antibiotic. Respondents who presented to fill their repeat prescription more than 2 weeks after the original prescription written were more likely not have consulted their doctor (p = 0.006, 95% CI [1.16, 2.01]) and not to know why their repeat was needed (p = 0.010, 95% CI [1.07,2.18]).Conclusions: Findings of this study suggested that the current 12 month validity of antibiotics repeat prescriptions is potentially contributing to patients’ self-diagnosis of URTIs and therefore potential misuse of antibiotics. This may be contributing to the rise of antimicrobial resistance. The study also outlines some common reasons for patients potentially self-diagnosing URTIs when using repeat prescriptions. Larger Australian studies are needed to confirm these findings

Sociodemographic profiles, educational attainment and physical activity associated with The Daily Mile™ registration in primary schools in England – a national cross-sectional linkage study

Objective To examine primary school and local authority characteristics associated with registration for The Daily Mile (TDM), an active mile initiative aimed at increasing physical activity in children. Design A cross-sectional linkage study using routinely collected data. Setting All state funded primary schools in England from 2012-2018(n=15,815). Results 3,502 of all 15,815(22.1%) state funded primary schools in England were registered to do TDM, ranging from 16% in the East Midlands region to 31% in Inner London. Primary schools registered for TDM had larger mean pupil numbers compared with schools that had not registered (300 vs 269 respectively). There was a higher proportion of TDM registered schools in urban areas compared with non-urban areas. There was local authority variation in the likelihood of school registration (ICC: 0.094). After adjusting for school and local authority characteristics, schools located in a major urban conurbation (OR 1.46 (95%CI:1.24-1.71) urban vs. rural) and schools with a higher proportion of disadvantaged pupils had higher odds of being registered to the TDM (OR 1.16 (95%CI:1.02-1.33)). Area based physical activity and schools’ educational attainment was not significantly associated with registration to TDM. Conclusion One in five primary schools in England has registered for The Daily Mile since 2012. TDM appears to be a wide-reaching school based physical activity intervention that is reaching more disadvantaged primary school populations in urban areas where obesity prevalence is highest. TDM registered schools include those with both high and low educational attainment and are in areas with high and low physical activit

Age-related decline in antibiotic prescribing for uncomplicated respiratory tract infections in primary care in England following the introduction of a national financial incentive (the Quality Premium) for health commissioners to reduce use of antibiotics in the community: an interrupted time series analysis

Objectives: To assess the impact of the 2015/16 NHS England Quality Premium (which provided a financial incentive for Clinical Commissioning Groups to reduce antibiotic prescribing in primary care) on antibiotic prescribing by General Practitioners (GPs) for respiratory tract infections (RTIs). Method: Interrupted time series analysis using monthly patient-level consultation and prescribing data obtained from the Clinical Practice Research Datalink (CPRD), between April 2011 and March 2017. The study population comprised patients consulting a GP who were diagnosed with an RTI. We assessed the rate of antibiotic prescribing in patients (both aggregate and stratified by age) with a recorded diagnosis of uncomplicated RTI, before and after the implementation of the Quality Premium. Results: Prescribing rates decreased over the six year study period, with evident seasonality. Notably, there was a 3% drop in the rate of antibiotic prescribing (equating to 14.65 prescriptions per 1,000 RTI consultations) (p<0.05) in April 2015, coinciding with the introduction of the Quality Premium. This reduction was sustained, such that after two years there was a 3% decrease in prescribing relative to that expected had the pre-intervention trend continued. There was also a concurrent 2% relative reduction in the rate of broad-spectrum antibiotic prescribing. Antibiotic prescribing for RTIs diagnosed in children showed the greatest decline with a 6% relative change two years after the intervention. Of the RTI indications studied, the greatest reductions in antibiotic prescribing were seen for patients with sore throats. Conclusions: Community prescribing of antibiotics for RTIs significantly decreased following the introduction of the Quality Premium, with the greatest reduction seen in younger patients

Sociodemographic profiles, educational attainment and physical activity associated with The Daily Mile™ registration in primary schools in England: a national cross-sectional linkage study

OBJECTIVE: To examine primary school and local authority characteristics associated with registration for The Daily Mile (TDM), an active mile initiative aimed at increasing physical activity in children. DESIGN: A cross-sectional linkage study using routinely collected data. SETTING: All state-funded primary schools in England from 2012 to 2018 (n=15,815). RESULTS: 3,502 of all 15,815 (22.1%) state-funded primary schools in England were registered to do TDM, ranging from 16% in the East Midlands region to 31% in Inner London. Primary schools registered for TDM had larger mean pupil numbers compared with schools that had not registered (300 vs 269, respectively). There was a higher proportion of TDM-registered schools in urban areas compared with non-urban areas. There was local authority variation in the likelihood of school registration (intraclass correlation coefficient: 0.094). After adjusting for school and local authority characteristics, schools located in a major urban conurbation (OR 1.46 (95% CI 1.24 to 1.71) urban vs rural) and schools with a higher proportion of disadvantaged pupils had higher odds of being registered for TDM (OR 1.16 (95% CI 1.02 to 1.33)). Area-based physical activity and schools' educational attainment were not significantly associated with registration to TDM. CONCLUSION: One in five primary schools in England has registered for TDM since 2012. TDM appears to be a wide-reaching school-based physical activity intervention that is reaching more disadvantaged primary school populations in urban areas where obesity prevalence is highest. TDM-registered schools include those with both high and low educational attainment and are in areas with high and low physical activity

How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals

Background: The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. Objectives: To understand responses to the QP and how it was perceived to influence antibiotic prescribing. Methods: Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. Results: The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. Conclusions: CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation

Report 29: The impact of the COVID-19 epidemic on all-cause attendances to emergency departments in two large London hospitals: an observational study

The health care system in England has been highly affected by the surge in demand due to patients afflicted by COVID-19. Yet the impact of the pandemic on the care seeking behaviour of patients and thus on Emergency department (ED) services is unknown, especially for non-COVID-19 related emergencies. In this report, we aimed to assess how the reorganisation of hospital care and admission policies to respond to the COVID-19 epidemic affected ED attendances and emergency hospital admissions. We performed time-series analyses of present year vs historic (2015-2019) trends of ED attendances between March 12 and May 31 at two large central London hospitals part of Imperial College Healthcare NHS Trust (ICHNT) and compared these to regional and national trends. Historic attendances data to ICHNT and publicly available NHS situation reports were used to calibrate time series auto-regressive integrated moving average (ARIMA) forecasting models. We thus predicted the (conterfactual) expected number of ED attendances between March 12 (when the first public health measure leading to lock-down started in England) to May 31, 2020 (when the analysis was censored) at ICHNT, at all acute London Trusts and nationally. The forecasted trends were compared to observed data for the same periods of time. Lastly, we analysed the trends at ICHNT disaggregating by mode of arrival, distance from postcode of patient residence to hospital and primary diagnosis amongst those that were subsequently admitted to hospital and compared these data to an average for the same period of time in the years 2015 to 2019. During the study period (January 1 to May 31, 2020) there was an overall decrease in ED attendances of 35% at ICHNT, of 50% across all London NHS Trusts and 53% nationally. For ICHNT, the decrease in attendances was mainly amongst those aged younger than 65 and those arriving by their own means (e.g. personal or public transport). Increasing distance (km) from postcode of residence to hospital was a significant predictor of reduced attendances, which could not be explained by weighted (for population numbers) mean index of multiple deprivation. Non-COVID emergency admissions to hospital after March 12 fell by 48% at ICHNT compared to previous years. This was seen across all disease areas, including acute coronary syndromes, stroke and cancer-related emergencies. The overall non-COVID-19 hospitalisation mortality risk did not differ (RR 1.13, 95%CI 0.94-1.37, p=0.19), also in comparison to previous years. Our findings suggest emergency healthcare seeking to hospitals drastically changed amongst the population within the catchment area of ICHNT. This trend was echoed regionally and nationally, suggesting those suffering a medical emergency may not have attended other (i.e. closer-to-home) hospitals. Furthermore, our time-series analyses showed that, even after COVID-19 cases and deaths decreased (i.e. from early April), non-COVID-19 ED attendances did not increase. The impact of emergency triaging systems (e.g. 111 calls) and alternative (e.g. private hospital, chemist) health services on these trends remains unknown. However, another recent report found increased non-COVID excess deaths in the community, which may be partially explained by people experiencing an emergency and not attending health services at all. Whether those that attended ED services have done so with longer delays from the moment of emergency onset also remains unknown. National analyses into the factors causing reduced attendances to ED services and strategies to revert these negative trends are urgently needed