The clinically extremely vulnerable to COVID: Identification and changes in healthcare while self-isolating (shielding) during the coronavirus pandemic

  1. Jessica E. Butler
  2. Mintu Nath
  3. Dimitra Blana
  4. William P. Ball
  5. Nicola Beech
  6. Corri Black
  7. Graham Osler
  8. Sebastien Peytrignet
  9. Katie Wilde
  10. Artur Wozniak
  11. Simon Sawhney

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Abstract

Background

In March 2020, the government of Scotland identified people deemed clinically extremely vulnerable to COVID due to their pre-existing health conditions. These people were advised to strictly self-isolate (shield) at the start of the pandemic, except for necessary healthcare. We examined who was identified as clinically extremely vulnerable, how their healthcare changed during isolation, and whether this process exacerbated healthcare inequalities.

Methods

We linked those on the shielding register in NHS Grampian, a health authority in Scotland, to healthcare records from 2015-2020. We described the source of identification, demographics, and clinical history of the cohort. We measured changes in out-patient, in-patient, and emergency healthcare during isolation in the shielding population and compared to the general non-shielding population.

Results

The register included 16,092 people (3% of the population), clinically vulnerable primarily due to a respiratory disease, immunosuppression, or cancer. Among them, 42% were not identified by national healthcare record screening but added ad hoc , with these additions including more children and fewer economically-deprived.

During isolation, all forms of healthcare use decreased (25%-46%), with larger decreases in scheduled care than in emergency care. However, people shielding had better maintained scheduled care compared to the non-shielding general population: out-patient visits decreased 35% vs 49%; in-patient visits decreased 46% vs 81%. Notably, there was substantial variation in whose scheduled care was maintained during isolation: younger people and those with cancer had significantly higher visit rates, but there was no difference between sexes or socioeconomic levels.

Conclusions

Healthcare changed dramatically for the clinically extremely vulnerable population during the pandemic. The increased reliance on emergency care while isolating indicates that continuity of care for existing conditions was not optimal. However, compared to the general population, there was success in maintaining scheduled care, particularly in young people and those with cancer. We suggest that integrating demographic and primary care data would improve identification of the clinically vulnerable and could aid prioritising their care.

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  1. ScreenIT

    SciScore for 10.1101/2021.09.09.21263026: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variableIdentification of the clinically extremely vulnerable: In Scotland, people were formally recognised as clinically extremely vulnerable if their medical records showed they were in one of six categories: people with solid organ transplants, specific cancers, severe respiratory conditions, rare diseases, who were pregnant with significant heart disease, and who were on immunosuppression therapies 12.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations include that the population covers a region that was somewhat less affected by coronavirus (COVID death rates at the end of the shielding period of 31st July 2020: 26 per 100,000 in Grampian compared to 47/100,000 in Scotland, 54/100,000 in Lothian and 63/100,000 in Greater Glasgow and Clyde30). An appropriate next step would be to scale these analyses across wider areas of Scotland and the UK. Rapid and reliable identification of the clinically vulnerable will continue to be important, and this analysis suggests two ways identification could be improved. First, sharing primary care records. In Scotland, primary care records are not shared nationally, limiting who could be identified as clinically extremely vulnerable to COVID and supported. Second, improving person-level sociodemographic data collection, including ethnicity. COVID hospital admissions and deaths have made it clear that sociodemographic characteristics affect clinical vulnerability to COVID. But in Scotland, ethnicity data are not well recorded, and the sociodemographic data available is for small areas rather than individuals. Neither ethnicity no socioeconomic data were not used to identify those who should shield. Collecting these data during healthcare visits and sharing them nationally could help improve care of the people who are clinically vulnerable. Healthcare changed dramatically for the clinically extremely vulnerable population during the pandemic. The increased reliance on emergency ca...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  2. Version published to 10.1101/2021.09.09.21263026v1 on medRxiv