Effects of the COVID-19 pandemic on the mental health of clinically extremely vulnerable children and children living with clinically extremely vulnerable people in Wales: a data linkage study

OBJECTIVES

To determine whether clinically extremely vulnerable (CEV) children or children living with a CEV person in Wales were at greater risk of presenting with anxiety or depression in primary or secondary care during the COVID-19 pandemic compared with children in the general population and to compare patterns of anxiety and depression during the pandemic (23 March 2020-31 January 2021, referred to as 2020/2021) and before the pandemic (23 March 2019-31 January 2020, referred to as 2019/2020), between CEV children and the general population.

DESIGN

Population-based cross-sectional cohort study using anonymised, linked, routinely collected health and administrative data held in the Secure Anonymised Information Linkage Databank. CEV individuals were identified using the COVID-19 shielded patient list.

SETTING

Primary and secondary healthcare settings covering 80% of the population of Wales.

PARTICIPANTS

Children aged 2-17 in Wales: CEV (3769); living with a CEV person (20 033); or neither (415 009).

PRIMARY OUTCOME MEASURE

First record of anxiety or depression in primary or secondary healthcare in 2019/2020 and 2020/2021, identified using Read and International Classification of Diseases V.10 codes.

RESULTS

A Cox regression model adjusted for demographics and history of anxiety or depression revealed that only CEV children were at greater risk of presenting with anxiety or depression during the pandemic compared with the general population (HR=2.27, 95% CI=1.94 to 2.66, p<0.001). Compared with the general population, the risk among CEV children was higher in 2020/2021 (risk ratio 3.04) compared with 2019/2020 (risk ratio 1.90). In 2020/2021, the period prevalence of anxiety or depression increased slightly among CEV children, but declined among the general population.

CONCLUSIONS

Differences in the period prevalence of recorded anxiety or depression in healthcare between CEV children and the general population were largely driven by a reduction in presentations to healthcare services by children in the general population during the pandemic.

How does the local area deprivation influence life chances for children in poverty in Wales: A record linkage cohort study

Objectives

Children growing up in poverty are less likely to achieve in school and more likely to experience mental health problems. This study examined factors in the local area that can help a child overcome the negative impact of poverty.

Design

A longitudinal record linkage retrospective cohort study.

Participants

This study included 159,131 children who lived in Wales and completed their age 16 exams (Key Stage 4 (KS4)) between 2009 and 2016. Free School Meal (FSM) provision was used as an indicator of household-level deprivation. Area-level deprivation was measured using the Welsh Index of Multiple Deprivation (WIMD) 2011. An encrypted unique Anonymous Linking Field was used to link the children with their health- and educational records.

Outcome measures

The outcome variable 'Profile to Leave Poverty' (PLP) was constructed based on successful completion of age 16 exams, no mental health condition, no substance and alcohol misuse records in routine data. Logistic regression with stepwise model selection was used to investigate the association between local area deprivation and the outcome variable.

Results

22% of children on FSM achieved PLP compared to 54.9% of non-FSM children. FSM Children from least deprived areas were significantly more likely to achieve PLP (adjusted odds ratio (aOR) - 2.20 (1.93, 2.51)) than FSM children from most deprived areas. FSM children, living in areas with higher community safety, higher relative income, higher access to services, were more likely to achieve PLP than their peers.

Conclusion

The findings indicate that community-level improvements such as increasing safety, connectivity and employment might help in child's education attainment, mental health and reduce risk taking behaviours.

Evaluation of the shielding initiative in Wales (EVITE Immunity): protocol for a quasiexperimental study

INTRODUCTION

Shielding aimed to protect those predicted to be at highest risk from COVID-19 and was uniquely implemented in the UK during the COVID-19 pandemic. Clinically extremely vulnerable people identified through algorithms and screening of routine National Health Service (NHS) data were individually and strongly advised to stay at home and strictly self-isolate even from others in their household. This study will generate a logic model of the intervention and evaluate the effects and costs of shielding to inform policy development and delivery during future pandemics.

METHODS AND ANALYSIS

This is a quasiexperimental study undertaken in Wales where records for people who were identified for shielding were already anonymously linked into integrated data systems for public health decision-making. We will: interview policy-makers to understand rationale for shielding advice to inform analysis and interpretation of results; use anonymised individual-level data to select people identified for shielding advice in March 2020 and a matched cohort, from routine electronic health data sources, to compare outcomes; survey a stratified random sample of each group about activities and quality of life at 12 months; use routine and newly collected blood data to assess immunity; interview people who were identified for shielding and their carers and NHS staff who delivered healthcare during shielding, to explore compliance and experiences; collect healthcare resource use data to calculate implementation costs and cost-consequences. Our team includes people who were shielding, who used their experience to help design and deliver this study.

ETHICS AND DISSEMINATION

The study has received approval from the Newcastle North Tyneside 2 Research Ethics Committee (IRAS 295050). We will disseminate results directly to UK government policy-makers, publish in peer-reviewed journals, present at scientific and policy conferences and share accessible summaries of results online and through public and patient networks.

How effective are population health surveys for estimating prevalence of chronic conditions compared to anonymised clinical data?

INTRODUCTION

Population health surveys are used to record person-reported outcome measures for chronic health conditions and provide a useful source of data when evaluating potential disease burdens. The reliability of survey-based prevalence estimates for chronic diseases is unclear nonetheless. This study applied methodological triangulation via a data linkage method to validate prevalence of selected chronic conditions (angina, myocardial infarction, heart failure, and asthma).

METHODS

Linked healthcare records were used for a combined cohort of 11,323 adults from the 2013 and 2014 sweeps of the Welsh Health Survey (WHS). The approach utilised consented survey data linked to primary and secondary care electronic health record (EHR) data back to 2002 within the Secure Anonymised Information Linkage (SAIL) Databank.

RESULTS

This descriptive study demonstrates validation of survey and clinical data using data linkage for selected chronic cardiovascular conditions and asthma with varied success. The results indicate that identifying cases for separate cardiovascular conditions was limited without specific medication codes for each condition, but more straightforward for asthma, where there was an extensive list of medications available. For asthma there was better agreement between prevalence estimates based on survey and clinical data as a result.

CONCLUSION

Whilst the results provide external validity for the WHS as an instrument for estimating the burden of chronic disease, they also indicate that a data linkage appproach can be used to produce comparable prevalence estimates using clinical data if a defined condition-specific set of clinical codes are available.

Impact of social deprivation on outcome following transcatheter aortic valve implantation (TAVI)

Objectives

We sought to evaluate whether socioeconomic status influences outcome after first-time transcatheter aortic valve implantation (TAVI).

Method

This is a single-centre study carried out in Swansea, South West Wales, UK between 5 November 2009 and 10 June 2018. Data included age, gender, domiciliary postal code, comorbidities, complications post-TAVI, length of stay, follow-up time and survival status. The Welsh Index of Multiple Deprivation, 2014 was used to stratify cases by level of social deprivation according to domiciliary postal codes.

Results

Study population was 387 patients of whom 213 (54.8%) were men with mean age ±SD of 82.8±8.3 years. Patients, who were less deprived (296 (76.4%)), were more likely to be older (83.5±7.9 vs 80.4±9.3, p<0.05) and to be married (83.2% vs 69.7%, p<0.05). Conversely, ‘more deprived’ patients (91 (23.6%)) were more likely to have a longer stay in hospital as compared with patients in the ‘less deprived group’ (29.6±32.7 days vs 21.3±21.1 days, p<0.05). However, 30-day, 1-year and 3-year survival/mortality rates were similar across all socioeconomic levels.

Conclusions

This is the first study in which social deprivation has been investigated as a risk factor for mortality in a high-risk group of patients with severe aortic stenosis undergoing TAVI. Residing in a ‘more deprived’ area in South West Wales is not associated with adverse outcome following TAVI but patients who are ‘more deprived’ tend to stay longer in hospital compared with patients who are ‘less deprived’.

Fuel Poverty Data Linking Project

Background with rationaleIn Wales, a household is considered to be in fuel poverty if it needs to spend more than 10% of its net income on maintaining a satisfactory heating regime. Addressing fuel poverty is particularly important to Wales with an estimated 29% of households in fuel poverty compared with 17% in the UK overall. To tackle fuel poverty in Wales, the Welsh Government implemented two fuel poverty schemes. Warm Homes Nest is a demand-led scheme and Warm Homes Arbed an area-based scheme. Both schemes provide free home energy efficiency measures e.g. home insulation or boilers. Main AimTo use linked administrative data to evaluate the impacts of Welsh Government home energy efficiency schemes for low income households. The findings will inform future fuel poverty schemes in Wales. Methods/ApproachIndividual-level data from both schemes was anonymously linked to routine health records, using the SAIL (Secure Anonymised Information Linkage) Databank, to examine the health service use of recipients. We used difference-in-difference estimations to compare any changes in the health of recipients before and after intervention with any concurrent change in health in those yet to receive an intervention. ResultsResults published in 2017 indicated positive effects for the Nest scheme, including positive impacts on respiratory health and general health. We will report results comparing the health impacts of the Arbed and Nest schemes. The study will be the first to directly compare the health impacts of a demand-led and an area-based energy efficiency scheme. Conclusion Providing home energy efficiency interventions has the potential to benefit population health; however, there is a scarcity of evidence comparing different methods of implementing schemes. Our findings will inform more effectively focussed home energy efficiency schemes and potentially improve the health of people living in Wales.

The Welsh Government Flying Start Data Linking Project

Background with rationale Flying Start is the Welsh Government’s (WG) flagship Early Years programme for families with children aged less than 4 years of age. Running since 2006, the four entitlements are: Enhanced Health Visiting Free part-time childcare for 2-3 year olds Parenting support Speech, language, and communication support Previous Flying Start evaluations have focused on area-based analysis to explore outcomes of Flying Start eligible children. The current project is the first to obtain individual level Flying Start data to look at outcomes around health, education and social care and to explore these outcomes in relation to levels of engagement with different entitlements of Flying Start. Main Aim The aim of the project is to link individual-level Flying Start intervention data with health, education and other data to investigate the potential impact of Flying Start. Methods/Approach Individual level data for Flying Start children is currently being obtained from six pilot Local Authorities in Wales using the Secure Anonymised Information Linkage (SAIL) databank. The Flying Start data will be linked to other data within the SAIL databank in order to investigate the impact of the Flying Start programme on a number of different outcomes including hospitalisations, Accident & Emergency (A&E) attendances, Primary Care interactions, educational attainment, school attendance and Special Educational Needs (SEN). Results The project will report on the emerging findings from the analysis of pilot data. It is anticipated that Flying Start dosage effects will also be investigated and reported on. Conclusion The findings will feed into the current evidence base for Flying Start and help to inform future policy-making. If successful, this model of evaluation is likely to be adopted by related WG programmes.

Are population health surveys reliable for self-reporting conditions and relative well-being for those with asthma?

BackgroundPerson reported population sample surveys have been used to record information on self-reported health for a number of years and provide a useful information source for studies of disease burdens. Developments since 2013 have led to integration of health-related quality of life and subjective well-being as topic areas in some UK-based health surveys. The relative impact of different morbidities on subjective well-being in the UK though is unclear and has not been extensively researched. ObjectivesThis descriptive study of a combined sample of two years of population-based data from the Welsh Health Survey (n=11,323) aims to address research questions relating to chronic conditions, self-reported health and well-being. The main questions are whether population surveys under- or overreport chronic conditions, and whether the relative level of mental wellbeing is different for those with chronic conditions to those without. Following this initial analysis it seeks to identify potential risk factors to mental wellbeing for those not affected by selected chronic conditions. MethodsSurvey data were linked with clinical data contained within the Secure Anonymised Information Linkage (SAIL) Databank using SQL (Structured Query Language). The association between selected chronic conditions and relative subjective well-being was then assessed using SF-36 Mental Component Scores as a measure of mental wellbeing. Analysis was based on contingency tables, graphs and logistic regression in SAS 9.4. FindingsResults show that some self-reported chronic conditions can more easily be verified than others from clinical data. Aside from the selected chronic conditions, potential risk factors to mental well-being include type 2 diabetes, a history of circulatory diseases, psychoactive substance abuse and hypertension. ConclusionsLinkage of survey data can provide useful insights into relative levels of self-reported illnesses and subjective well-being but can also be used effectively to explore the risks that other morbidities present to mental wellbeing.