Population-level impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in the people with COVID-19 in England: a national analysis using a stepped wedge design

  1. Thomas Beaney
  2. Jonathan Clarke
  3. Ahmed Alboksmaty
  4. Kelsey Flott
  5. Aidan Fowler
  6. Jonathan Benger
  7. Paul P Aylin
  8. Sarah Elkin
  9. Ana Luisa Neves
  10. Ara Darzi

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Abstract

To identify the population-level impact of a national pulse oximetry remote monitoring programme for COVID-19 (COVID Oximetry @home (CO@h)) in England on mortality and health service use.

Methods

We conducted a retrospective cohort study using a stepped wedge pre-implementation and post-implementation design, including all 106 Clinical Commissioning Groups (CCGs) in England implementing a local CO@h programme. All symptomatic people with a positive COVID-19 PCR test result from 1 October 2020 to 3 May 2021, and who were aged ≥65 years or identified as clinically extremely vulnerable were included. Care home residents were excluded. A pre-intervention period before implementation of the CO@h programme in each CCG was compared with a post-intervention period after implementation. Five outcome measures within 28 days of a positive COVID-19 test: (i) death from any cause; (ii) any ED attendance; (iii) any emergency hospital admission; (iv) critical care admission and (v) total length of hospital stay.

Results

217 650 people were eligible and included in the analysis. Total enrolment onto the programme was low, with enrolment data received for only 5527 (2.5%) of the eligible population. The period of implementation of the programme was not associated with mortality or length of hospital stay. The period of implementation was associated with increased health service utilisation with a 12% increase in the odds of ED attendance (95% CI: 6% to 18%) and emergency hospital admission (95% CI: 5% to 20%) and a 24% increase in the odds of critical care admission in those admitted (95% CI: 5% to 47%). In a secondary analysis of CO@h sites with at least 10% or 20% of eligible people enrolled, there was no significant association with any outcome measure.

Conclusion

At a population level, there was no association with mortality before and after the implementation period of the CO@h programme, and small increases in health service utilisation were observed. However, lower than expected enrolment is likely to have diluted the effects of the programme at a population level.

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  1. Version published to 10.1136/emermed-2022-212378
  2. ScreenIT

    SciScore for 10.1101/2021.11.29.21266847: (What is this?)

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

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Python v3.9.5 and Pandas v1.2.3 were used in data manipulation.
    Python
    suggested: (IPython, RRID:SCR_001658)

    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:
    Strengths and limitations: A strength of this study is the availability of comprehensive data on covid-19 testing, defining a robust denominator population. Through linkage to primary and secondary care records, we identified the eligible population and adjusted for underlying risk factors differing between the population pre- and post-implementation. Eligibility for the programme was not absolute, with NHS England recommending an extended age threshold of 50 years and over from February 2021. Our analysis focussed on a narrower subgroup of people aged 65 or over or CEV, who would have remained eligible over the full study period, but as a result, findings might not be generalisable to all those included in the programme. The stepped wedge design was chosen in part as it is robust to biases in decisions regarding onboarding of patients (such as systematic onboarding of higher or lower risk patients), which would impact individual level study designs. The effect estimates are also not impacted by lack of submission of patient-level programme data on patients onboarded, which may not be complete. However, incompleteness of received data does impact on our ability to judge the degree to which the study was adequately powered to detect a difference in mortality should one exist. The primary analysis adjusted for patient covariates, for which data were incomplete. However, the impact on the estimates is unlikely to be significant, as sensitivity analyses adjusted for patient-level...

    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

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  3. Version published to 10.1101/2021.11.29.21266847v1 on medRxiv