Ruth E. Costello et al.
Ethnic differences in the indirect effects of the COVID-19 pandemic on clinical monitoring and hospitalisations for non-COVID conditions in England: a population-based, observational cohort study using the OpenSAFELY platform
The Lancet, June 2023; doi.org/10.1016/j.eclinm.2023.102077
Abstract
The COVID-19 pandemic disrupted healthcare and may have impacted ethnic inequalities in healthcare. We aimed to describe the impact of pandemic-related disruption on ethnic differences in clinical monitoring and hospital admissions for non-COVID conditions in England.
Methods
In this population-based, observational cohort study we used primary care electronic health record data with linkage to hospital episode statistics data and mortality data within OpenSAFELY, a data analytics platform created, with approval of NHS England, to address urgent COVID-19 research questions. We included adults aged 18 years and over registered with a TPP practice between March 1, 2018, and April 30, 2022. We excluded those with missing age, sex, geographic region, or Index of Multiple Deprivation. We grouped ethnicity (exposure), into five categories: White, Asian, Black, Other, and Mixed. We used interrupted time-series regression to estimate ethnic differences in clinical monitoring frequency (blood pressure and Hba1c measurements, chronic obstructive pulmonary disease and asthma annual reviews) before and after March 23, 2020. We used multivariable Cox regression to quantify ethnic differences in hospitalisations related to diabetes, cardiovascular disease, respiratory disease, and mental health before and after March 23, 2020.
Findings
Of 33,510,937 registered with a GP as of 1st January 2020, 19,064,019 were adults, alive and registered for at least 3 months, 3,010,751 met the exclusion criteria and 1,122,912 were missing ethnicity. This resulted in 14,930,356 adults with known ethnicity (92% of sample): 86.6% were White, 7.3% Asian, 2.6% Black, 1.4% Mixed ethnicity, and 2.2% Other ethnicities. Clinical monitoring did not return to pre-pandemic levels for any ethnic group. Ethnic differences were apparent pre-pandemic, except for diabetes monitoring, and remained unchanged, except for blood pressure monitoring in those with mental health conditions where differences narrowed during the pandemic. For those of Black ethnicity, there were seven additional admissions for diabetic ketoacidosis per month during the pandemic, and relative ethnic differences narrowed during the pandemic compared to the White ethnic group (Pre-pandemic hazard ratio (HR): 0.50, 95% confidence interval (CI) 0.41, 0.60, Pandemic HR: 0.75, 95% CI: 0.65, 0.87). There was increased admissions for heart failure during the pandemic for all ethnic groups, though highest in those of White ethnicity (heart failure risk difference: 5.4). Relatively, ethnic differences narrowed for heart failure admission in those of Asian (Pre-pandemic HR 1.56, 95% CI 1.49, 1.64, Pandemic HR 1.24, 95% CI 1.19, 1.29) and Black ethnicity (Pre-pandemic HR 1.41, 95% CI: 1.30, 1.53, Pandemic HR: 1.16, 95% CI 1.09, 1.25) compared with White ethnicity. For other outcomes the pandemic had minimal impact on ethnic differences.
Interpretation
Our study suggests that ethnic differences in clinical monitoring and hospitalisations remained largely unchanged during the pandemic for most conditions. Key exceptions were hospitalisations for diabetic ketoacidosis and heart failure, which warrant further investigation to understand the causes.
Nafiso Ahmed et al.
Mental health in Europe during the COVID-19 pandemic: a systematic review
The Lancet, June 2023; doi.org/10.1016/S2215-0366(23)00113-X
Abstract
The COVID-19 pandemic caused immediate and far-reaching disruption to society, the economy, and health-care services. We synthesised evidence on the effect of the pandemic on mental health and mental health care in high-income European countries. We included 177 longitudinal and repeated cross-sectional studies comparing prevalence or incidence of mental health problems, mental health symptom severity in people with pre-existing mental health conditions, or mental health service use before versus during the pandemic, or between different timepoints of the pandemic. We found that epidemiological studies reported higher prevalence of some mental health problems during the pandemic compared with before it, but that in most cases this increase reduced over time. Conversely, studies of health records showed reduced incidence of new diagnoses at the start of the pandemic, which further declined during 2020. Mental health service use also declined at the onset of the pandemic but increased later in 2020 and through 2021, although rates of use did not return to pre-pandemic levels for some services. We found mixed patterns of effects of the pandemic on mental health and social outcome for adults already living with mental health conditions.
XiaominZhong et al
Impact of COVID-19 on broad-spectrum antibiotic prescribing for common infections in primary care in England: a time-series analyses using OpenSAFELY and effects of predictors including deprivation
The Lancet, May 2023; doi.org/10.1016/j.lanepe.2023.100653
Abstract
The COVID-19 pandemic impacted the healthcare systems, adding extra pressure to reduce antimicrobial resistance. Therefore, we aimed to evaluate changes in antibiotic prescription patterns after COVID-19 started.
Methods
With the approval of NHS England, we used the OpenSAFELY platform to access the TPP SystmOne electronic health record (EHR) system in primary care and selected patients prescribed antibiotics from 2019 to 2021. To evaluate the impact of COVID-19 on broad-spectrum antibiotic prescribing, we evaluated prescribing rates and its predictors and used interrupted time series analysis by fitting binomial logistic regression models.
Findings
Over 32 million antibiotic prescriptions were extracted over the study period; 8.7% were broad-spectrum. The study showed increases in broad-spectrum antibiotic prescribing (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.36–1.38) as an immediate impact of the pandemic, followed by a gradual recovery with a 1.1–1.2% decrease in odds of broad-spectrum prescription per month. The same pattern was found within subgroups defined by age, sex, region, ethnicity, and socioeconomic deprivation quintiles. More deprived patients were more likely to receive broad-spectrum antibiotics, which differences remained stable over time. The most significant increase in broad-spectrum prescribing was observed for lower respiratory tract infection (OR 2.33; 95% CI 2.1–2.50) and otitis media (OR 1.96; 95% CI 1.80–2.13).
Interpretation
An immediate reduction in antibiotic prescribing and an increase in the proportion of broad-spectrum antibiotic prescribing in primary care was observed. The trends recovered to pre-pandemic levels, but the consequence of the COVID-19 pandemic on AMR needs further investigation.
Neeti S. Kulkarni et al.
Alcohol-Associated Liver Disease Mortality Rates by Race Before and During the COVID-19 Pandemic in the US
JAMA, Aoril 2023; doi:10.1001/jamahealthforum.2023.0527
Abstract
In 2021, US life expectancy dropped to its lowest level since 1996, with the largest decline among the non-Hispanic American Indian or Alaska Native population.1 The leading cause of death for this group, other than COVID-19 and unintentional injuries, was chronic liver disease (CLD).1 Recent growth in CLD prevalence is primarily associated with an increase in alcohol-associated liver disease (ALD).2 Rates of ALD increased by 43% from 2009 to 2015, accounting for over $5 billion in direct health care costs in 2015.3 This problem was exacerbated by the COVID-19 pandemic, during which ALD deaths increased by 22.4%.4 Given the acceleration of ALD and the burden of CLD for American Indian or Alaska Native populations, we conducted a study to understand the association between race and ALD mortality at the state level before and during the pandemic.
The highest AAMR in 2019 was 95.3 per 100 000 people in South Dakota and in 2020 was 199.4 per 100 000 people in Wyoming, both among American Indian or Alaska Native people. Among states with available data, the mean AAMR in this population was nearly 6-fold higher than in White people, the group with the second highest rates (68.5 vs 11.7 per 100 000 people). In these states, American Indian or Alaska Native populations accounted for 9.6% of all ALD deaths, yet represented only 3.2% of the 2020 total population.
Omair A. Shariq et al.
Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic
JAMA, Marc h 2023; doi:10.1001/jamanetworkopen.2023.1198
Abstract
Importance The American College of Surgeons (ACS) has advocated for the expansion of outpatient surgery to conserve limited hospital resources and bed capacity, while maintaining surgical throughput, during the COVID-19 pandemic.
Objective To investigate the association of the COVID-19 pandemic with outpatient scheduled general surgery procedures.
Design, Setting, and Participants This multicenter, retrospective cohort study analyzed data from hospitals participating in the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from January 1, 2016, to December 31, 2019 (before COVID-19), and from January 1 to December 31, 2020 (during COVID-19). Adult patients (≥18 years of age) who underwent any 1 of the 16 most frequently performed scheduled general surgery operations in the ACS-NSQIP database were included.
Main Outcomes and Measures The primary outcome was the percentage of outpatient cases (length of stay, 0 days) for each procedure. To determine the rate of change over time, multiple multivariable logistic regression models were used to assess the independent association of year with the odds of outpatient surgery.
Conclusions and Relevance In this cohort study, the first year of the COVID-19 pandemic was associated with an accelerated transition to outpatient surgery for many scheduled general surgical operations; however, the magnitude of percentage increase was small for all but 4 procedure types. Further studies should explore potential barriers to the uptake of this approach, particularly for procedures that have been shown to be safe when performed in an outpatient setting.
Samuel R. Wittman et al.
Antibiotic Receipt During Outpatient Visits for COVID-19 in the US, From 2020 to 2022
Jamanetwork, February 2023; doi:10.1001/jamahealthforum.2022.5429
Abstract
Introduction
Approximately 30% of outpatient COVID-19–related visits among Medicare beneficiaries have resulted in a filled antibiotic prescription.1 We examined antibiotic receipt at COVID-19–related visits for commercially insured individuals aged 0 to 64 years.
Discussion
Antibiotic receipt at COVID-19–related visits was substantially lower for children and adolescents than adults and varied by region and site of care. Increased prescriptions in adults may be associated with a higher prevalence of comorbidities and higher risks of adverse outcomes.
The findings that, among both adults and those aged 6 to 17 years, antibiotic receipt was highest at ED and practice-based telemedicine visits and that azithromycin was the most common were consistent with prior results.1 Azithromycin might be selected for its potential anti-inflammatory and antiviral properties, especially before more data were available.4 Amoxicillin use among the youngest group suggests concerns about associated (but undiagnosed) bacterial infection such as otitis media or pneumonia.
Study limitations included the lack of data on Medicaid-covered encounters or visits by uninsured individuals. Additionally, data were collected when pediatric visits and antibiotic use for non–COVID-19 ARTI-related visits were lower than usual.5 The ICD-10 code U07.1 appears highly specific but not as sensitive for COVID-19–related visits.6 Claims data did not include prescribed but not filled antibiotics or antibiotics purchased without insurance. We also did not examine how severity of illness or presence of comorbidities was associated with antibiotic use. Understanding these prescribing practices will inform efforts to improve antibiotic stewardship.
IaneCoutinho et al.
The impact of the COVID-19 pandemic in tuberculosis preventive treatment in Brazil: a retrospective cohort study using secondary data
The Lancet, February 2023; doi.org/10.1016/j.lana.2023.100444
Abstract
Background
Disruptions in tuberculosis services have been reported around the world since the emergence of the COVID-19 pandemic. However, the pandemic's effect on tuberculosis preventive treatment (TPT) has been poorly explored. We compared TPT-notified prescriptions and outcomes before and during the pandemic in Brazil.
Methods
Retrospective cohort using secondary data from the Brazilian TPT information system in five cities with over 1000 notifications. The number of TPT prescriptions was analysed from 6 months after healthcare workers’ training, in 2018, to July 2021. The proportion of TPT outcomes by the date of treatment initiation was analysed up to the end of 2020, as most outcomes of TPT started in 2021 were still unknown in July 2021. Joinpoint regression was used to evaluate trends.
Findings
14,014 TPT prescriptions were included, most from São Paulo (8032) and Rio de Janeiro (3187). Compared to the same epidemiological weeks in 2019, the number of TPT prescribed in 2020 increased in Rio de Janeiro (82%) and São Paulo (14%) and decreased in Recife (65%), Fortaleza (31%) and Manaus (44%). In 2021, however, there was a 93% reduction in TPT prescriptions in all cities. The proportion of completed TPT remained constant (median = 74%).
Interpretation
The COVID-19 pandemic in Brazil was associated with a dramatic decrease in TPT prescriptions in 2021. Treatment adherence remained constant, suggesting that health services were able to keep people on treatment but did not perform well in providing opportunities for people to enter care. Efforts are needed to expand access to TPT.
Doan C et al.
Breast and Lung Cancer Screening Among Medicare Enrollees During the COVID-19 Pandemic
JAMA, February 2023; doi:10.1001/jamanetworkopen.2022.55589
Abstract
Importance Several studies reported sharp decreases in screening mammography for breast cancer and low-dose computed tomographic screening for lung cancer in the early months of the COVID-19 pandemic, followed by a return to normal or near-normal levels in the summer of 2020.
Objective To determine the observed vs expected mammography and low-dose computed tomographic scan rates from the beginning of the pandemic through April 2022.
Design, Setting, and Participants In this retrospective cohort study assessing mammography and low-dose computed tomography rates from January 2017 through April 2022, data for January 2016 to February 2020 were used to generate expected rates for the period March 2020 to April 2022. The study included a 20% national sample of Medicare fee-for-service enrollees among women aged 50 to 74 years for mammography, and men and women aged 55 to 79 years for low-dose computed tomographic scan.
Main Outcomes and Measures Receipt of screening mammography or low-dose computed tomographic scan.
Results The yearly cohorts for the mammography rates included more than 1 600 000 women aged 50 to 74 years, and the cohorts for the low-dose computed tomographic scan rates included more than 3 700 000 men and women aged 55 to 79 years. From January 2017 through February 2020, monthly mammography rates were flat, whereas there was a monotonic increase in low-dose computed tomographic scan rates, from approximately 500 per million per month in early 2017 to 1100 per million per month by January 2020. Over the period from March 2020 to April 2022, there were episodic drops in both mammography and low-dose computed tomographic scan rates, coincident with increases in national COVID-19 infection rates. For the periods from March 2020 to February 2020 and March 2021 to February 2022, the observed low-dose computed tomographic scan rates were 24% (95% CI, 23%-24%) and 14% (95% CI, 13%-15%) below expected rates, whereas mammography rates were 17% (95% CI, 17%-18%) and 4% (95% CI, 4%-3%) below expected.
Conclusions and Relevance In this cohort study, the decreases in cancer screening during the early phases of the COVID-19 pandemic did not resolve after the initial pandemic surges. Successful interventions to improve screening rates should address pandemic-specific reasons for low screening participation.
HaoLuo et al.
Rates of Antipsychotic Drug Prescribing Among People Living With Dementia During the COVID-19 Pandemic
JAMA, January 2023; doi:10.1001/jamapsychiatry.2022.4448
Abstract
Importance Concerns have been raised that the use of antipsychotic medication for people living with dementia might have increased during the COVID-19 pandemic.
Objective To examine multinational trends in antipsychotic drug prescribing for people living with dementia before and during the COVID-19 pandemic.
Design, Setting, and Participants This multinational network cohort study used electronic health records and claims data from 8 databases in 6 countries (France, Germany, Italy, South Korea, the UK, and the US) for individuals aged 65 years or older between January 1, 2016, and November 30, 2021. Two databases each were included for South Korea and the US.
Exposures The introduction of population-wide COVID-19 restrictions from April 2020 to the latest available date of each database.
Main Outcomes and Measures The main outcomes were yearly and monthly incidence of dementia diagnosis and prevalence of people living with dementia who were prescribed antipsychotic drugs in each database. Interrupted time series analyses were used to quantify changes in prescribing rates before and after the introduction of population-wide COVID-19 restrictions.
Conclusions and Relevance This cohort study found converging evidence that the rate of antipsychotic drug prescribing to people with dementia increased in the initial months of the COVID-19 pandemic in the 6 countries studied and did not decrease to prepandemic levels after the acute phase of the pandemic had ended. These findings suggest that the pandemic disrupted the care of people living with dementia and that the development of intervention strategies is needed to ensure the quality of care.
Bryant O.K. et al.
Antibiotic prescribing in general practice during COVID-19 and beyond
Lancet, December 2022; doi.org/10.1016/S1473-3099(22)00814-3
Abstract
Richard Armitage and Laura B Nellums1 reported that when accounting for changes in appointment numbers, the total number of antibiotics prescribed between April 1, and Aug 31, 2020, was 6·71% higher than expected—a statistically significant increase.
By use of updated data, we were able to assess whether the increase was sustained throughout the pandemic and beyond. OpenPrescribing publishes monthly data for the number of items prescribed in general practice in England, UK. National Health Service (NHS) England provides monthly data for appointment activity in general practice.
We conducted an interrupted time-series analysis using the negative binomial model and data from Jan 1, 2018, to July 31, 2022. Interruptions were set at the months of March, 2020, the start of the pandemic, and July, 2021, when restrictions were lifted in England, UK. All data and analysis code are available online.Our data provide little population-level evidence of an association between telephone appointments and inappropriate antibiotic stewardship, because prescribing rates have continued to decrease despite a high proportion of general practice appointments being conducted via telephone.
Clinicians should still be supported to use antibiotics appropriately. However, when considering the impact of the total pandemic restrictions in England, UK, there is little evidence that COVID-19 has hindered attempts by the NHS to reduce antibiotic prescribing on the whole.
