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Randell RL, Hornik CP, Curtis L, Hernandez AF, Denwood T, Nebeker C, Sugarman J, Tyl B, Murakami M, Oley Wilberforce L, Pagoto S, Vedin O, Andersson T, Carrasquillo O, Dolor R, Kollins SH, Pellegrino J, Ranney ML. "Click and mortar" opportunities for digitization and consumerism in trials. Contemp Clin Trials 2023; 132:107304. [PMID: 37481202 PMCID: PMC10530120 DOI: 10.1016/j.cct.2023.107304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/28/2023] [Accepted: 07/19/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Digitization (using novel digital tools and strategies) and consumerism (taking a consumer-oriented approach) are increasingly commonplace in clinical trials, but the implications of these changes are not well described. METHODS We assembled a group of trial experts from academia, industry, non-profit, and government to discuss implications of this changing trial landscape and provide guidance. RESULTS Digitization and consumerism can increase the volume and diversity of trial participants and expedite recruitment. However, downstream bottlenecks, challenges with retention, and serious issues with equity, ethics, and security can result. A "click and mortar" approach, combining approaches from novel and traditional trials with the thoughtful use of technology, may optimally balance opportunities and challenges facing many trials. CONCLUSION We offer expert guidance and three "click and mortar" approaches to digital, consumer-oriented trials. More guidance and research are needed to navigate the associated opportunities and challenges.
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Affiliation(s)
- Rachel L Randell
- Duke University, School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University, Durham, NC, USA.
| | - Christoph P Hornik
- Duke University, School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Lesley Curtis
- Duke University, School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Adrian F Hernandez
- Duke University, School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Tom Denwood
- Population Health Partners LLPShort Hills, NJ, USA
| | - Camille Nebeker
- Herbert Wertheim School of Public Health & Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics and Department of Medicine,Johns Hopkins University, Baltimore, MD, USA
| | - Benoit Tyl
- Bayer Healthcare SAS, La Garenne Colombes, France
| | | | | | - Sherry Pagoto
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | | | | | - Olveen Carrasquillo
- Division of General Internal Medicine Co-Director, Miami Clinical & Translational Science Institute (CTSI), University of Miami, Miami, FL, USA
| | - Rowena Dolor
- Duke University, School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Scott H Kollins
- Duke University, School of Medicine, Durham, NC, USA; Akili, Inc, Boston, MA, USA
| | | | - Megan L Ranney
- School of Public Health, Yale University, New Haven, CT, USA
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Sydes MR, Barbachano Y, Bowman L, Denwood T, Farmer A, Garfield-Birkbeck S, Gibson M, Gulliford MC, Harrison DA, Hewitt C, Logue J, Navaie W, Norrie J, O'Kane M, Quint JK, Rycroft-Malone J, Sheffield J, Smeeth L, Sullivan F, Tizzard J, Walker P, Wilding J, Williamson PR, Landray M, Morris A, Walker RR, Williams HC, Valentine J. Realising the full potential of data-enabled trials in the UK: a call for action. BMJ Open 2021; 11:e043906. [PMID: 34135032 PMCID: PMC8211043 DOI: 10.1136/bmjopen-2020-043906] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 04/26/2021] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Clinical trials are the gold standard for testing interventions. COVID-19 has further raised their public profile and emphasised the need to deliver better, faster, more efficient trials for patient benefit. Considerable overlap exists between data required for trials and data already collected routinely in electronic healthcare records (EHRs). Opportunities exist to use these in innovative ways to decrease duplication of effort and speed trial recruitment, conduct and follow-up. APPROACH The National Institute of Health Research (NIHR), Health Data Research UK and Clinical Practice Research Datalink co-organised a national workshop to accelerate the agenda for 'data-enabled clinical trials'. Showcasing successful examples and imagining future possibilities, the plenary talks, panel discussions, group discussions and case studies covered: design/feasibility; recruitment; conduct/follow-up; collecting benefits/harms; and analysis/interpretation. REFLECTION Some notable studies have successfully accessed and used EHR to identify potential recruits, support randomised trials, deliver interventions and supplement/replace trial-specific follow-up. Some outcome measures are already reliably collected; others, like safety, need detailed work to meet regulatory reporting requirements. There is a clear need for system interoperability and a 'route map' to identify and access the necessary datasets. Researchers running regulatory-facing trials must carefully consider how data quality and integrity would be assessed. An experience-sharing forum could stimulate wider adoption of EHR-based methods in trial design and execution. DISCUSSION EHR offer opportunities to better plan clinical trials, assess patients and capture data more efficiently, reducing research waste and increasing focus on each trial's specific challenges. The short-term emphasis should be on facilitating patient recruitment and for postmarketing authorisation trials where research-relevant outcome measures are readily collectable. Sharing of case studies is encouraged. The workshop directly informed NIHR's funding call for ambitious data-enabled trials at scale. There is the opportunity for the UK to build upon existing data science capabilities to identify, recruit and monitor patients in trials at scale.
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Affiliation(s)
- Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - Louise Bowman
- MRC Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Andrew Farmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Steph Garfield-Birkbeck
- Trials and Studies Coordinating Centre, National Institute for Health Research Evaluation, Southampton, UK
| | | | - Martin C Gulliford
- King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, The University of York, York, UK
| | | | | | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Martin O'Kane
- Medicines and Healthcare products Regulatory Agency (MHRA), London, UK
| | - Jennifer K Quint
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London, London, UK
| | - Jo Rycroft-Malone
- Lancaster University, Lancaster, UK
- NIHR Health Services & Delivery Programme, Southampton, UK
| | | | - Liam Smeeth
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frank Sullivan
- Division of Population & Behavioural Science, University of St. Andrews, St Andrews, UK
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Paula Walker
- Medicines and Healthcare products Regulatory Agency (MHRA), London, UK
| | - John Wilding
- Department of Cardiovasular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Paula R Williamson
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Martin Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Health Data Research UK, University of Oxford, Oxford, UK
| | | | | | - Hywel C Williams
- University of Nottingham, Nottingham, UK
- Director of the NIHR Health Technology Assessment Programme (2015-2020), Southampton, UK
| | - Janet Valentine
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
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Macnair A, Love SB, Murray ML, Gilbert DC, Parmar MKB, Denwood T, Carpenter J, Sydes MR, Langley RE, Cafferty FH. Accessing routinely collected health data to improve clinical trials: recent experience of access. Trials 2021; 22:340. [PMID: 33971933 PMCID: PMC8108438 DOI: 10.1186/s13063-021-05295-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/24/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Routinely collected electronic health records (EHRs) have the potential to enhance randomised controlled trials (RCTs) by facilitating recruitment and follow-up. Despite this, current EHR use is minimal in UK RCTs, in part due to ongoing concerns about the utility (reliability, completeness, accuracy) and accessibility of the data. The aim of this manuscript is to document the process, timelines and challenges of the application process to help improve the service both for the applicants and data holders. METHODS This is a qualitative paper providing a descriptive narrative from one UK clinical trials unit (MRC CTU at UCL) on the experience of two trial teams' application process to access data from three large English national datasets: National Cancer Registration and Analysis Service (NCRAS), National Institute for Cardiovascular Outcomes Research (NICOR) and NHS Digital to establish themes for discussion. The underpinning reason for applying for the data was to compare EHRs with data collected through case report forms in two RCTs, Add-Aspirin (ISRCTN 74358648) and PATCH (ISRCTN 70406718). RESULTS The Add-Aspirin trial, which had a pre-planned embedded sub-study to assess EHR, received data from NCRAS 13 months after the first application. In the PATCH trial, the decision to request data was made whilst the trial was recruiting. The study received data after 8 months from NICOR and 15 months for NHS Digital following final application submission. This concluded in May 2020. Prior to application submission, significant time and effort was needed particularly in relation to the PATCH trial where negotiations over consent and data linkage took many years. CONCLUSIONS Our experience demonstrates that data access can be a prolonged and complex process. This is compounded if multiple data sources are required for the same project. This needs to be factored in when planning to use EHR within RCTs and is best considered prior to conception of the trial. Data holders and researchers are endeavouring to simplify and streamline the application process so that the potential of EHR can be realised for clinical trials.
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Affiliation(s)
- Archie Macnair
- MRC Clinical Trials Unit at UCL, UCL, London, WC1V 6LJ UK
- Health Data Research UK, London, UK
| | - Sharon B. Love
- MRC Clinical Trials Unit at UCL, UCL, London, WC1V 6LJ UK
- Health Data Research UK, London, UK
| | - Macey L. Murray
- MRC Clinical Trials Unit at UCL, UCL, London, WC1V 6LJ UK
- Health Data Research UK, London, UK
| | | | | | - Tom Denwood
- NHS Digital, 1 Trevelyan Square, Leeds, LS1 6AE UK
| | - James Carpenter
- MRC Clinical Trials Unit at UCL, UCL, London, WC1V 6LJ UK
- Health Data Research UK, London, UK
- Medical Statistics, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, UCL, London, WC1V 6LJ UK
- Health Data Research UK, London, UK
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Wu J, Mamas MA, Mohamed MO, Kwok CS, Roebuck C, Humberstone B, Denwood T, Luescher T, de Belder MA, Deanfield JE, Gale CP. Place and causes of acute cardiovascular mortality during the COVID-19 pandemic. Heart 2021; 107:113-119. [PMID: 32988988 PMCID: PMC7523172 DOI: 10.1136/heartjnl-2020-317912] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To describe the place and causes of acute cardiovascular death during the COVID-19 pandemic. METHODS Retrospective cohort of adult (age ≥18 years) acute cardiovascular deaths (n=5 87 225) in England and Wales, from 1 January 2014 to 30 June 2020. The exposure was the COVID-19 pandemic (from onset of the first COVID-19 death in England, 2 March 2020). The main outcome was acute cardiovascular events directly contributing to death. RESULTS After 2 March 2020, there were 28 969 acute cardiovascular deaths of which 5.1% related to COVID-19, and an excess acute cardiovascular mortality of 2085 (+8%). Deaths in the community accounted for nearly half of all deaths during this period. Death at home had the greatest excess acute cardiovascular deaths (2279, +35%), followed by deaths at care homes and hospices (1095, +32%) and in hospital (50, +0%). The most frequent cause of acute cardiovascular death during this period was stroke (10 318, 35.6%), followed by acute coronary syndrome (ACS) (7 098, 24.5%), heart failure (6 770, 23.4%), pulmonary embolism (2 689, 9.3%) and cardiac arrest (1 328, 4.6%). The greatest cause of excess cardiovascular death in care homes and hospices was stroke (715, +39%), compared with ACS (768, +41%) at home and cardiogenic shock (55, +15%) in hospital. CONCLUSIONS AND RELEVANCE The COVID-19 pandemic has resulted in an inflation in acute cardiovascular deaths, nearly half of which occurred in the community and most did not relate to COVID-19 infection suggesting there were delays to seeking help or likely the result of undiagnosed COVID-19.
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Affiliation(s)
- Jianhua Wu
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Division of Clinical and Translational Research, School of Dentistry, University of Leeds, Leeds, UK
| | - Mamas A Mamas
- Keele Cardiovascular Reserach Group, Keele University, Keele, Staffordshire, UK
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Research Institute for Primary Care and Health Sciences, Keele, UK
| | - Chun Shing Kwok
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | | | | | | | | | | | | | - Chris P Gale
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Leeds Insitutue of Cardiovascualr and Metabolic Medicine, University of Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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5
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Kwok CS, Gale CP, Curzen N, de Belder MA, Ludman P, Lüscher TF, Kontopantelis E, Roebuck C, Denwood T, Burton T, Hains J, Deanfield JE, Mamas MA. Impact of the COVID-19 Pandemic on Percutaneous Coronary Intervention in England: Insights From the British Cardiovascular Intervention Society PCI Database Cohort. Circ Cardiovasc Interv 2020; 13:e009654. [PMID: 33138626 DOI: 10.1161/circinterventions.120.009654] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of the study was to evaluate changes in percutaneous coronary intervention (PCI) practice in England by analyzing procedural numbers, changes in the clinical presentation, and characteristics of patients and their clinical outcomes during the coronavirus disease 2019 (COVID-19) pandemic. METHODS We conducted a retrospective cohort study of all patients who underwent PCI in England between January 2017 and April 2020 in the British Cardiovascular Intervention Society database. RESULTS Forty-four hospitals reported PCI procedures for 126 491 patients. There were ≈700 procedures performed each week before the lockdown. After the March 23, 2020 lockdown (11th/12th week in 2020), there was a 49% fall in the number of PCI procedures after the 12th week in 2020. The decrease was greatest in PCI procedures performed for stable angina (66%), followed by non-ST-segment-elevation myocardial infarction (45%), and ST-segment-elevation myocardial infarction (33%). Patients after the lockdown were younger (64.5 versus 65.5 years, P<0.001) and less likely to have diabetes (20.4% versus 24.6%, P<0.001), hypertension (52.0% versus 56.8%, P=0.001), previous myocardial infarction (23.5% versus 26.7%, P=0.008), previous PCI (24.3% versus 28.3%, P=0.001), or previous coronary artery bypass graft (4.6% versus 7.2%, P<0.001) compared with before the lockdown. CONCLUSIONS The lockdown in England has resulted in a significant decline in PCI procedures. Fewer patients underwent PCI for stable angina. This enabled greater capacity for urgent and emergency cases, and a reduced length of stay was seen for such patients. Significant changes in the characteristics of patients towards a lower risk phenotype were observed, particularly for non-ST-segment-elevation myocardial infarction, reflecting a more conservative approach to this cohort.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.).,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.)
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine (C.P.G.), University of Leeds, United Kingdom.,Leeds Institute for Data Analytics (C.P.G.), University of Leeds, United Kingdom.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, United Kingdom (C.P.G.)
| | - Nick Curzen
- Wessex Cardiothoracic Unit, Southampton University Hospital Southampton & Faculty of Medicine University of Southampton, United Kingdom (N.C.)
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, United Kingdom (M.A.d.B., J.H., J.E.D.)
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (P.L.)
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospital Trust, Imperial College London, United Kingdom (T.F.L.).,Centre for Molecular Cardiology, University of Zurich, Switzerland (T.F.L.)
| | - Evangelos Kontopantelis
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, United Kingdom (E.K.)
| | - Chris Roebuck
- NHS Digital, Leeds, United Kingdom (C.R., T.D., T.B.)
| | - Tom Denwood
- NHS Digital, Leeds, United Kingdom (C.R., T.D., T.B.)
| | - Tony Burton
- NHS Digital, Leeds, United Kingdom (C.R., T.D., T.B.)
| | - Julian Hains
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, United Kingdom (M.A.d.B., J.H., J.E.D.)
| | - John E Deanfield
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, United Kingdom (M.A.d.B., J.H., J.E.D.).,Department of Cardiology, Great Ormond Street Hospital, University College London, United Kingdom (J.E.D.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.).,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.)
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6
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Rashid Hons M, Gale Hons CP, Curzen Hons N, Ludman Hons P, De Belder Hons M, Timmis Hons A, Mohamed Hons MO, Lüscher Hons TF, Hains Hons J, Wu J, Shoaib A, Kontopantelis E, Roebuck C, Denwood T, Deanfield J, Mamas MA. Impact of Coronavirus Disease 2019 Pandemic on the Incidence and Management of Out-of-Hospital Cardiac Arrest in Patients Presenting With Acute Myocardial Infarction in England. J Am Heart Assoc 2020; 9:e018379. [PMID: 33023348 PMCID: PMC7763705 DOI: 10.1161/jaha.120.018379] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Studies have reported significant reduction in acute myocardial infarction-related hospitalizations during the coronavirus disease 2019 (COVID-19) pandemic. However, whether these trends are associated with increased incidence of out-of-hospital cardiac arrest (OHCA) in this population is unknown. Methods and Results Acute myocardial infarction hospitalizations with OHCA during the COVID-19 period (February 1-May 14, 2020) from the Myocardial Ischaemia National Audit Project and British Cardiovascular Intervention Society data sets were analyzed. Temporal trends were assessed using Poisson models with equivalent pre-COVID-19 period (February 1-May 14, 2019) as reference. Acute myocardial infarction hospitalizations during COVID-19 period were reduced by >50% (n=20 310 versus n=9325). OHCA was more prevalent during the COVID-19 period compared with the pre-COVID-19 period (5.6% versus 3.6%), with a 56% increase in the incidence of OHCA (incidence rate ratio, 1.56; 95% CI, 1.39-1.74). Patients experiencing OHCA during COVID-19 period were likely to be older, likely to be women, likely to be of Asian ethnicity, and more likely to present with ST-segment-elevation myocardial infarction. The overall rates of invasive coronary angiography (58.4% versus 71.6%; P<0.001) were significantly lower among the OHCA group during COVID-19 period with increased time to reperfusion (mean, 2.1 versus 1.1 hours; P=0.05) in those with ST-segment-elevation myocardial infarction. The adjusted in-hospital mortality probability increased from 27.7% in February 2020 to 35.8% in May 2020 in the COVID-19 group (P<.001). Conclusions In this national cohort of hospitalized patients with acute myocardial infarction, we observed a significant increase in incidence of OHCA during COVID-19 period paralleled with reduced access to guideline-recommended care and increased in-hospital mortality.
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Affiliation(s)
- Muhammad Rashid Hons
- Keele Cardiovascular Research Group Institute for Prognosis Research School of Primary Care Keele University Newcastle UK.,Department of Cardiology Royal Stoke Hospital Stoke-on-Trent UK
| | - Chris P Gale Hons
- Leeds Institute for Data Analytics University of Leeds Leeds UK.,Leeds Teaching Hospitals NHS Trust Leeds UK.,Leeds Institute for Cardiovascular and Metabolic Medicine University of Leeds Leeds UK
| | - Nick Curzen Hons
- Coronary Research Group University Hospital Southampton and Faculty of Medicine University of Southampton Southampton UK
| | - Peter Ludman Hons
- Department of Cardiology Queen Elizabeth Hospital Birmingham Birmingham UK
| | - Mark De Belder Hons
- National Institute for Cardiovascular Outcomes Research Barts Health NHS Trust London UK
| | | | - Mohamed O Mohamed Hons
- Keele Cardiovascular Research Group Institute for Prognosis Research School of Primary Care Keele University Newcastle UK.,Department of Cardiology Royal Stoke Hospital Stoke-on-Trent UK
| | - Thomas F Lüscher Hons
- Royal Brompton and Harefield Hospitals and Imperial College London UK.,Center for Molecular Cardiology University of Zürich Zürich Switzerland
| | - Julian Hains Hons
- National Institute for Cardiovascular Outcomes Research Barts Health NHS Trust London UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics University of Leeds Leeds UK.,Leeds Teaching Hospitals NHS Trust Leeds UK.,Leeds Institute for Cardiovascular and Metabolic Medicine University of Leeds Leeds UK
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group Institute for Prognosis Research School of Primary Care Keele University Newcastle UK.,Department of Cardiology Royal Stoke Hospital Stoke-on-Trent UK
| | - Evangelos Kontopantelis
- Division of Population Health Health Services Research and Primary Care University of Manchester Manchester UK
| | | | | | - John Deanfield
- Institute of Cardiovascular Sciences University College London London UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group Institute for Prognosis Research School of Primary Care Keele University Newcastle UK.,Department of Cardiology Royal Stoke Hospital Stoke-on-Trent UK.,Department of Medicine Thomas Jefferson University Philadelphia PA
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7
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Mohamed MO, Gale CP, Kontopantelis E, Doran T, de Belder M, Asaria M, Luscher T, Wu J, Rashid M, Stephenson C, Denwood T, Roebuck C, Deanfield J, Mamas MA. Sex Differences in Mortality Rates and Underlying Conditions for COVID-19 Deaths in England and Wales. Mayo Clin Proc 2020; 95:2110-2124. [PMID: 33012342 PMCID: PMC7377724 DOI: 10.1016/j.mayocp.2020.07.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/12/2020] [Accepted: 07/20/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To address the issue of limited national data on the prevalence and distribution of underlying conditions among COVID-19 deaths between sexes and across age groups. PATIENTS AND METHODS All adult (≥18 years) deaths recorded in England and Wales (March 1, 2020, to May 12, 2020) were analyzed retrospectively. We compared the prevalence of underlying health conditions between COVID and non-COVID-related deaths during the COVID-19 pandemic and the age-standardized mortality rate (ASMR) of COVID-19 compared with other primary causes of death, stratified by sex and age group. RESULTS Of 144,279 adult deaths recorded during the study period, 36,438 (25.3%) were confirmed COVID deaths. Women represented 43.2% (n=15,731) of COVID deaths compared with 51.9% (n=55,980) in non-COVID deaths. Overall, COVID deaths were younger than non-COVID deaths (82 vs 83 years). ASMR of COVID-19 was higher than all other common primary causes of death, across age groups and sexes, except for cancers in women between the ages of 30 and 79 years. A linear relationship was observed between ASMR and age among COVID-19 deaths, with persistently higher rates in men than women across all age groups. The most prevalent reported conditions were hypertension, dementia, chronic lung disease, and diabetes, and these were higher among COVID deaths. Pre-existing ischemic heart disease was similar in COVID (11.4%) and non-COVID (12%) deaths. CONCLUSION In a nationwide analysis, COVID-19 infection was associated with higher age-standardized mortality than other primary causes of death, except cancer in women of select age groups. COVID-19 mortality was persistently higher in men and increased with advanced age.
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Affiliation(s)
- Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Chris P Gale
- Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom; Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, United Kingdom
| | - Tim Doran
- Department of Health Sciences, University of York, York, United Kingdom
| | - Mark de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, United Kingdom
| | | | - Thomas Luscher
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Jianhua Wu
- Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | | | | | | | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom.
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8
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Kwok CS, Gale CP, Kinnaird T, Curzen N, Ludman P, Kontopantelis E, Wu J, Denwood T, Fazal N, Deanfield J, de Belder MA, Mamas M. Impact of COVID-19 on percutaneous coronary intervention for ST-elevation myocardial infarction. Heart 2020; 106:1805-1811. [PMID: 32868280 DOI: 10.1136/heartjnl-2020-317650] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The objective of the study was to identify any changes in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in England by analysing procedural numbers, clinical characteristics and patient outcomes during the COVID-19 pandemic. METHODS We conducted a retrospective cohort study of patients who underwent PCI in England between January 2017 and April 2020 in the British Cardiovascular Intervention Society-National Institute of Cardiovascular Outcomes Research database. Analysis was restricted to 44 hospitals that reported contemporaneous activity on PCI. Only patients with primary PCI for STEMI were included in the analysis. RESULTS A total of 34 127 patients with STEMI (primary PCI 33 938, facilitated PCI 108, rescue PCI 81) were included in the study. There was a decline in the number of procedures by 43% (n=497) in April 2020 compared with the average monthly procedures between 2017 and 2019 (n=865). For all patients, the median time from symptom to hospital showed increased after the lockdown (150 (99-270) vs 135 (89-250) min, p=0.004) and a longer door-to-balloon time after the lockdown (48 (21-112) vs 37 (16-94) min, p<0.001). The in-hospital mortality rate was 4.8% before the lockdown and 3.5% after the lockdown (p=0.12). Following adjustment for baseline characteristics, no differences were observed for in-hospital death (OR 0.87, 95% CI 0.45 to 1.68, p=0.67) and major adverse cardiovascular events (OR 0.71, 95% CI 0.39 to 1.32, p=0.28). CONCLUSIONS Following the lockdown in England, we observed a decline in primary PCI procedures for STEMI and increases in overall symptom-to-hospital and door-to-balloon time for patients with STEMI. Restructuring health services during COVID-19 has not adversely influenced in-hospital outcomes.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Keele, Staffordshire, UK
| | - Chris P Gale
- Division of Epidemiology and Biostatistics, University of Leeds, Leeds, UK
| | - Tim Kinnaird
- Keele Cardiovascular Research Group, Keele University, Keele, Staffordshire, UK.,Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Nick Curzen
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Evan Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, Greater Manchester, UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics, University of Leeds, Leeds, West Yorkshire, UK.,Division of Clinical and Translational Research, School of Dentistry, University of Leeds, Leeds, UK
| | | | - Nadeem Fazal
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, UK
| | - John Deanfield
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, UK
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, UK
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, Staffordshire, UK
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Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, Hollings S, Roebuck C, Gale CP, Mamas MA, Deanfield JE, de Belder MA, Luescher TF, Denwood T, Landray MJ, Emberson JR, Collins R, Morris EJA, Casadei B, Baigent C. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet 2020; 396:381-389. [PMID: 32679111 PMCID: PMC7429983 DOI: 10.1016/s0140-6736(20)31356-8] [Citation(s) in RCA: 458] [Impact Index Per Article: 114.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/29/2020] [Accepted: 06/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several countries affected by the COVID-19 pandemic have reported a substantial drop in the number of patients attending the emergency department with acute coronary syndromes and a reduced number of cardiac procedures. We aimed to understand the scale, nature, and duration of changes to admissions for different types of acute coronary syndrome in England and to evaluate whether in-hospital management of patients has been affected as a result of the COVID-19 pandemic. METHODS We analysed data on hospital admissions in England for types of acute coronary syndrome from Jan 1, 2019, to May 24, 2020, that were recorded in the Secondary Uses Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), myocardial infarction of unknown type, or other acute coronary syndromes (including unstable angina). We identified revascularisation procedures undertaken during these admissions (ie, coronary angiography without percutaneous coronary intervention [PCI], PCI, and coronary artery bypass graft surgery). We calculated the numbers of weekly admissions and procedures undertaken; percentage reductions in weekly admissions and across subgroups were also calculated, with 95% CIs. FINDINGS Hospital admissions for acute coronary syndrome declined from mid-February, 2020, falling from a 2019 baseline rate of 3017 admissions per week to 1813 per week by the end of March, 2020, a reduction of 40% (95% CI 37-43). This decline was partly reversed during April and May, 2020, such that by the last week of May, 2020, there were 2522 admissions, representing a 16% (95% CI 13-20) reduction from baseline. During the period of declining admissions, there were reductions in the numbers of admissions for all types of acute coronary syndrome, including both STEMI and NSTEMI, but relative and absolute reductions were larger for NSTEMI, with 1267 admissions per week in 2019 and 733 per week by the end of March, 2020, a percent reduction of 42% (95% CI 38-46). In parallel, reductions were recorded in the number of PCI procedures for patients with both STEMI (438 PCI procedures per week in 2019 vs 346 by the end of March, 2020; percent reduction 21%, 95% CI 12-29) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%, 29-45). The median length of stay among patients with acute coronary syndrome fell from 4 days (IQR 2-9) in 2019 to 3 days (1-5) by the end of March, 2020. INTERPRETATION Compared with the weekly average in 2019, there was a substantial reduction in the weekly numbers of patients with acute coronary syndrome who were admitted to hospital in England by the end of March, 2020, which had been partly reversed by the end of May, 2020. The reduced number of admissions during this period is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease. The full extent of the effect of COVID-19 on the management of patients with acute coronary syndrome will continue to be assessed by updating these analyses. FUNDING UK Medical Research Council, British Heart Foundation, Public Health England, Health Data Research UK, and the National Institute for Health Research Oxford Biomedical Research Centre.
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Affiliation(s)
- Marion M Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Enti Spata
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK
| | - Raphael Goldacre
- Big Data Institute, Nuffield Department of Population Health, Oxford, UK
| | | | | | | | | | | | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Prognosis Research, University of Keele, Keele, UK
| | - John E Deanfield
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, UK
| | - Thomas F Luescher
- Imperial College, National Heart and Lung Institute, London, UK; Royal Brompton and Harefield Hospitals, London, UK
| | | | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK; Big Data Institute, Nuffield Department of Population Health, Oxford, UK
| | - Jonathan R Emberson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Eva J A Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Big Data Institute, Nuffield Department of Population Health, Oxford, UK
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK.
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