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

Aiming at the Global Elimination of Viral Hepatitis: Challenges along the Care Continuum

A recent international workshop, organised by the authors, analysed the obstacles facing the ambitious goal of eliminating viral hepatitis globally. We identified several policy areas critical to reaching elimination targets. These include: providing hepatitis B birth-dose vaccination to all infants within 24 hours of birth; preventing the transmission of blood-borne viruses through the expansion of national haemovigilance schemes; implementing the lessons learnt from the HIV epidemic regarding safe medical practices to eliminate iatrogenic infection; adopting point-of-care testing to improve coverage of diagnosis; and providing free or affordable hepatitis C treatment to all. We introduce Egypt as a case study for rapid testing and treatment scale-up: this country offers valuable insights to policy makers internationally, not only regarding how hepatitis C interventions can be expeditiously scaled-up, but also as a guide for how to tackle the problems encountered with such ambitious testing and treatment programmes

Report 17: Clinical characteristics and predictors of outcomes of hospitalised patients with COVID-19 in a London NHS Trust: a retrospective cohort study

Clinical characteristics and determinants of outcomes for hospitalised COVID-19 patients in the UK remain largely undescribed and emerging evidence suggests ethnic minorities might be disproportionately affected. We describe the characteristics and outcomes of patients hospitalised for COVID-19 in three large London hospitals with a multi-ethnic catchment population. We performed a retrospective cohort study on all patients hospitalised with laboratory-confirmed SARS-CoV-2 infection at Imperial College Healthcare NHS Trust between February 25 and April 5, 2020. Outcomes were recorded as of April 19, 2020. Logistic regression models, survival analyses and cumulative competing risk analyses were performed to evaluate factors associated with COVID-19 hospital mortality. Of 520 patients in this cohort (median age 67 years, (IQR 26) and 62% male), 302 (68%) had been discharged alive, 144 (32%) died and 74 (14%) were still hospitalised at the time of censoring. Increasing age (adjusted odds ratio [aOR] 2·16, 95%CI 1·50-3·12), severe hypoxia (aOR 3·75, 95%CI 1·80-7·80), low platelets (aOR 0·65, 95%CI 0.49·0·85), reduced estimated glomerular filtration rate (aOR 4·11, 95%CI 1·58-10·69), bilirubin >21mmol/L (aOR 2·32, 95%CI 1·05-5·14) and low albumin (aOR 0·77, 9%%CI 0·59-1·01) were associated with increased risk of in-hospital mortality. Individual comorbidities were not independently associated with risk of death. Regarding ethnicity, 209 (40%) were from a black and Asian minority, for 115 (22%) ethnicity was unknown and 196 (38%) patients were white. Compared to the latter, black patients were significantly younger and had less comorbidities. Whilst the crude OR of death of black compared to white patients was not significant (1·14, 95%CI 0·69-1·88, p=0.62), adjusting for age and comorbidity showed a trend towards significance (aOR 1·72, 95%CI 0·98-3·02, p=0.06) and further accounting for admission severity (Early Warning Score) showed a significant difference (aOR 1·83 95% CI 1·02-3·30, p=0.04). In the first study to describe the characteristics and predictors of outcome for hospitalised COVID-19 patients in the UK, we find that older age, male sex and admission hypoxia, thrombocytopenia, renal failure, hypoalbuminaemia and raised bilirubin are associated with increased odds of death. Ethnic minority groups were over-represented in our cohort and, compared to whites, people of black ethnicity may be at increased odds of mortality. Further research is urgently needed to investigate these associations on a larger scale

Understanding the Potential Impact of Different Drug Properties On SARS-CoV-2 Transmission and Disease Burden: A Modelling Analysis

Background The public health impact of the COVID-19 pandemic has motivated a rapid search for potential therapeutics, with some key successes. However, the potential impact of different treatments, and consequently research and procurement priorities, have not been clear. Methods Using a mathematical model of SARS-CoV-2 transmission, COVID-19 disease and clinical care, we explore the public-health impact of different potential therapeutics, under a range of scenarios varying healthcare capacity, epidemic trajectories; and drug efficacy in the absence of supportive care. Results The impact of drugs like dexamethasone (delivered to the most critically-ill in hospital and whose therapeutic benefit is expected to depend on the availability of supportive care such as oxygen and mechanical ventilation) is likely to be limited in settings where healthcare capacity is lowest or where uncontrolled epidemics result in hospitals being overwhelmed. As such, it may avert 22% of deaths in high-income countries but only 8% in low-income countries (assuming R=1.35). Therapeutics for different patient populations (those not in hospital, early in the course of infection) and types of benefit (reducing disease severity or infectiousness, preventing hospitalisation) could have much greater benefits, particularly in resource-poor settings facing large epidemics. Conclusions Advances in the treatment of COVID-19 to date have been focussed on hospitalised-patients and predicated on an assumption of adequate access to supportive care. Therapeutics delivered earlier in the course of infection that reduce the need for healthcare or reduce infectiousness could have significant impact, and research into their efficacy and means of delivery should be a priority

The impact of the timely birth-dose vaccine on the global elimination of hepatitis B

In 2016 the World Health Organization set the goal of eliminating hepatitis B globally by 2030. Horizontal transmission has been greatly reduced in most countries by scaling up coverage of the infant HBV vaccine series, and vertical transmission is therefore becoming increasingly dominant. Here we show that scaling up timely hepatitis B birth dose vaccination to 90% of new-borns in 110 low- and middle-income countries by 2030 could prevent 710,000 (580,000 to 890,000) deaths in the 2020 to 2030 birth cohorts compared to status quo, with the greatest benefits in Africa. Maintaining this could lead to elimination by 2030 in the Americas, but not before 2059 in Africa. Drops in coverage due to disruptions in 2020 may lead to 15,000 additional deaths, mostly in South-East Asia and the Western Pacific. Delays in planned scale-up could lead to an additional 580,000 deaths globally in the 2020 to 2030 birth cohorts

Cost-effectiveness of strategies to improve HCV screening, linkage-to-care and treatment in remand prison settings in England.

BACKGROUND: A simplified cascade-of-care may improve screening and treatment uptake among incarcerated individuals. We assessed the cost-effectiveness of traditional and simplified screening and treatment in a London remand prison. METHODS: Using empirical data from Her Majesty's Prison (HMP) Wormwood Scrubs, London, we designed a decision tree and Markov transition state model using national average data for HCV screening and treatment for the base-case scenario. This was compared two alternative strategies; (1) general prison population screening and treatment and (2) prioritising screening and treatment among people who inject drugs (PWID) combined with general prison population screening and treatment. Strategies varied the rates of screening (47-90%), linkage-to-care (60-86%) and treatment (21-85%). Cost, utility and disease transition rates were obtained from existing literature. Outcome measures were; screening, treatment and disease-related costs per admitted individual, quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs) were calculated for each intervention. All costs and utilities were discounted at a rate of 3.5% per annum. Both univariate and probabilistic sensitivity analyses have been conducted. RESULTS: In our cohort of 5,239 incarcerated individuals with an estimated chronic HCV prevalence of 2.6%, all strategy ICER values (£3,565-10,300) fell below the national willingness to pay threshold (£30,000). Increased successful treatment (7-54%) was observed by an optimising cascade-of-care. A robust sensitivity analysis identified treatment cost of, QALY for mild liver disease and probability of completing treatment as important factors that impact the ICER value. CONCLUSION: In our remand setting, optimising adherence to the cascade-of-care is cost-effective. Where universal screening is not practical, a stratified approach focused on intensive screening and treatment of PWID also results in increased treatment uptake and is highly cost-effective

Report 27 Adapting hospital capacity to meet changing demands during the COVID-19 pandemic

To meet the growing demand for hospital care due to the COVID-19 pandemic, England implemented a range of hospital provision interventions including the procurement of equipment, the establishment of additional hospital facilities and the redeployment of staff and other resources. Additionally, to further release capacity across England’s National Health Service (NHS), elective surgery was cancelled in March 2020, leading to a backlog of patients requiring care. This created a pressure on the NHS to reintroduce elective procedures, which urgently needs to be addressed. Population-level measures implemented in March and April 2020 reduced transmission of SARS-CoV-2, prompting a gradual decline in the demand for hospital care by COVID-19 patients after the peak in mid-April. Planning capacity to bring back routine procedures for non-COVID-19 patients whilst maintaining the ability to respond to any potential future increases in demand for COVID-19 care is the challenge currently faced by healthcare planners. In this report, we aim to calculate hospital capacity for emergency treatment of COVID-19 and other patients during the pandemic surge in April and May 2020; to evaluate the increase in capacity achieved via five interventions (cancellation of elective surgery, field hospitals, use of private hospitals, and deployment of former and newly qualified medical staff); and to determine how to re-introduce elective surgery considering continued demand from COVID-19 patients. We do this by modelling the supply of acute NHS hospital care, considering different capacity scenarios, namely capacity before the pandemic (baseline scenario) and after the implementation of capacity expansion interventions that impact available general and acute (G&A) and critical care (CC) beds, staff and ventilators. Demand for hospital care is accounted for in terms of non-COVID-19 and COVID-19 patients. Our results suggest that NHS England would not have had sufficient daily capacity to treat all patients without implementing hospital provision interventions. With interventions in place at the peak of the epidemic, there would be no capacity to treat elective CC patients. CC shortfalls would have been driven by a lack of nurses, beds and junior doctors; G&A care would have been limited by bed numbers. If interventions are not maintained, 10% of elective CC patients can be treated once the number of COVID-19 patients has fallen to 1,210; 100% of elective CC patients can be treated once the number of COVID-19 CC patients has fallen to 320. Hospital provision interventions would allow 10% of CC electives to be treated once the number of COVID-19 CC patients has fallen to 2,530 and 100% of CC electives once the number of COVID-19 CC patients has fallen to 1,550. To accommodate all elective G&A patients, the interventions should not be scaled back until the number of COVID-19 G&A patients falls below 7,500. We conclude that such interventions need to be sustained for patients requiring care to be treated, especially if there are future surges in COVID-19 patients requiring hospitalisation

Report 15: Strengthening hospital capacity for the COVID-19 pandemic

Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for COVID-19, and other conditions, is one of the most challenging tasks facing healthcare commissioners and care providers during the pandemic. Due to uncertainty in expected patient numbers requiring care, as well as evolving needs day by day, planning hospital capacity is challenging. Health systems that are well prepared for the pandemic can better cope with large and sudden changes in demand by implementing strategies to ensure adequate access to care. Thereby the burden of the pandemic can be mitigated, and many lives saved. This report presents the J-IDEA pandemic planner, a hospital planning tool to calculate how much capacity in terms of beds, staff and ventilators is obtained by implementing healthcare provision interventions affecting the management of patient care in hospitals. We show how to assess baseline capacity, and then calculate how much capacity is gained by various healthcare interventions using impact estimates that are generated as part of this study. Interventions are informed by a rapid review of policy decisions implemented or being considered in 12 European countries over the past few months , an evaluation of the impact of the interventions on capacity using a variety of research methods, and by a review of key parameters in the care of COVID-19 patients. The J-IDEA planner is publicly available, interactive and adaptable to different and changing circumstances and newly emerging evidence. The planner estimates the additional number of beds, medical staff and crucial medical equipment obtained under various healthcare interventions using flexible inputs on assumptions of existing capacities, the number of hospitalisations, beds-to-staff ratios, and staff absences due to COVID-19. A detailed user guide accompanies the planner. The planner was developed rapidly and has limitations which we will address in future iterations. It supports decision-makers in delivering a fast, effective and coordinated response to the pandemic that upholds the aims that societies have set for their healthcare systems and the medical treatment of their citizens. We welcome feedback from users of the tool and readers of this report to help us to update the tool iteratively