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Background The COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Though the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing. Methods We used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote vs face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 - March 2022. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for patient-, clinician- and practice-level factors. Findings There were 45,997 ARI consultations (34,555 unique patients), of which 28,127 were remote and 17,870 face-to-face. For children, 48% of consultations were remote whereas for adults 66% were remote. For children, 42% of remote and 43% face-to-face consultations led to an antibiotic prescription; the equivalent in adults was 52% of remote and 42% face-to-face. Adults with a remote consultation had 23% (Odds Ratio (OR) 1.23 95% Confidence Interval (CI): 1.18-1.29) higher chance of being prescribed antibiotics compared to if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1.04 95% CI 0.98-1.11). Interpretation This study uses rich patient-level data and robust statistical methods and represents an important contribution to the evidence base on antibiotic prescribing in post-COVID primary care. The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes. Funding No external funding. Keywords general practice; England; antibiotics; remote consultations; telehealth; telemedicine; TMLE; causal inference; machine learning; acute respiratory infections; antimicrobial resistance; covid; ARTI; ARI; antibiotic prescribing; primary care

Background The COVID-19 pandemic has severely impacted healthcare delivery and there are growing concerns that the pandemic will accelerate antimicrobial resistance. Objectives To evaluate the impact of the COVID-19 pandemic on antibiotic prescribing in a tertiary paediatric hospital in London, UK. Methods Data on patient characteristics and antimicrobial administration for inpatients treated between 29 April 2019 and Sunday 28 March 2021 were extracted from the electronic health record (EHR). Interrupted time series analysis was used to evaluate antibiotic days of therapy (DOT) and the proportion of prescribed antibiotics from the WHO ‘Access’ class. Results A total of 23 292 inpatient admissions were included. Prior to the pandemic there were an average 262 admissions per week compared with 212 during the pandemic period. Patient demographics were similar in the two periods but there was a shift in the specialities that patients had been admitted to. During the pandemic, there was a crude increase in antibiotic DOTs, from 801 weekly DOT before the pandemic to 846. The proportion of Access antibiotics decreased from 44% to 42%. However, after controlling for changes in patient characteristics, there was no evidence for the pandemic having an impact on antibiotic prescribing. Conclusions The patient population in a specialist children’s hospital was affected by the COVID-19 pandemic, but after adjusting for these changes there was no evidence that antibiotic prescribing was significantly affected by the pandemic. This highlights both the value of routine, high-quality EHR data and importance of appropriate statistical methods that can adjust for underlying changes to populations when evaluating impacts of the pandemic on healthcare.

BackgroundThe COVID-19 pandemic has had a significant impact on primary care service delivery. With general practice delivering record numbers of appointments and rising concerns around access, funding and staffing in the UK National Health Service, we assessed contemporary trends in consultation rate and mode (face-to-face versus remote).MethodsWe did a retrospective analysis of 9,429,919 consultations by GP, nurse or other health care professional between March 2018 and February 2022 for patients registered at 397 English general practices. We used routine electronic health records from Clinical Practice Research Datalink Aurum with linkage to national datasets. Negative binomial models were used to predict consultation rates and modes (remote versus face-to-face) by age, sex, and socio-economic deprivation.FindingsOverall consultation rates increased by 15% from 4.92 in 2018-19 to 5.66 in 2021-22 with some fluctuation during the start of the pandemic. Consultation rates increased with deprivation. The breakdown into face-to-face and remote consultations shows that the pandemic precipitated a rapid increase in remote consultations across all groups but varies by age. Socioeconomic differences in consultation rate, adjusted for sex and age, halved during the pandemic (from 0.36 to 0.18 more consultations in the most deprived). The most deprived saw a relatively larger increase in remote and decrease in face-to-face consultations rates.InterpretationSubstantial increases in consultation rates imply increased pressure on general practice. The narrowing of consultation rates between deprivation quintiles is cause for concern, given ample evidence that health needs are greater in more deprived areas.FundingNo external funding.Research in contextEvidence before this studyPressure on general practice has increased over recent years and there is consensus that the COVID-19 pandemic added to this. There is also consensus that the way general practice is delivering care has changed with increased use of remote consultation but there no estimates of the full extent of this and uptake by different groups. A seminal paper - Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14 – found an increase in consultation rates over the study period and in increased reliance on telephone contacts even before the pandemic.Added value of this studyThis study reports recent data for general practice consultation rates overall and by delivery mode. Our findings show that overall consultation rates were higher in 2021-22 than prior to the pandemic and that there has been a shift from face-to-face to remote consultations. However, the increase in overall consultations rates varies between index of multiple deprivation quintiles when adjusting for age and sex. These findings are based on close to 10 million consultations and 2 million person-years of observation from a validated data base of routinely collected electronic clinical records (the Clinical Practice Research Datalink Aurum).Implications of all the available evidenceOur analysis shows that general practice is busier than ever. We provide details on the use of remote versus face-to-face consultations by different patient groups over time. The narrowing of the difference between consultation rates of deprivation quintiles implies increasing health inequality in the population as existing differences in health needs are therefore not fully reflected in the consultation rates. The relatively larger increase in remote consultation rates and drop in face-to-face consultations for the most deprived provides detail on what type of consultations different patient groups receive but also raises additional questions.

ObjectiveTo compare hospital activity, patient casemix and medication prescribing and administration before and during the COVID-19 emergency.DesignRetrospective observational studySettingA specialist children’s hospital in the UKPatientsInpatients aged 25 and younger treated at a specialist children’s hospital between 29 April 2019 and 6 September 2020ResultsThere were 21,471 day cases and inpatients treated during the 16 month study period. Day cases (no overnight stay) dropped by around 37% per week. Both admissions and discharges for inpatients (at least one overnight stay) decreased leading to a small reduction in hospital bed days but no reduction in hospital bed nights. The effect on hospital activity on different patient groups varied substantially with some groups such as medical oncology day cases increasing by 13%. As a result, the patient case mix in the hospital was very different during the pandemic. Overall weekly medication administrations decreased for day cases and inpatients, but weekly medication administrations per bed day increased by 10% for day cases and 6% for inpatients.ConclusionsDespite not being badly affected by the disease itself, specialist paediatric hospital services have been greatly affected by the pandemic. The average number of medications per inpatient bed day increased, likely reflecting changes to the patient population, with only those children with severe conditions being treated during the pandemic. These data demonstrate the complex pattern of implications on specialist services and provide evidence for planning the impact of future emergencies and resolution strategies.

Introduction Stroke registries are used in many settings to measure stroke treatment and outcomes, but rarely include data on health economic outcomes. We aimed to extend the Sentinel Stroke National Audit Programme registry of England, Wales and Northern Ireland to derive and report patient-level estimates of the cost of stroke care. Methods An individual patient simulation model was built to estimate health and social care costs at one and five years after stroke, and the cost-benefits of thrombolysis and early supported discharge. Costs were stratified according to age, sex, stroke type (ischaemic or primary intracerebral haemorrhage) and stroke severity. The results were illustrated using data on all patients with stroke included in Sentinel Stroke National Audit Programme from April 2015 to March 2016 (n = 84,184). Results The total cost of health and social care for patients with acute stroke each year in England, Wales and Northern Ireland was £3.60 billion in the first five years after admission (mean per patient cost: £46,039). There was fivefold variation in the magnitude of costs between patients, ranging from £19,101 to £107,336. Costs increased with older age, increasing stroke severity and intracerebral hemorrhage stroke. Increasing the proportion of eligible patients receiving thrombolysis or early supported discharge was estimated to save health and social care costs by five years after stroke. Discussion The cost of stroke care is large and varies widely between patients. Increasing the proportion of eligible patients receiving thrombolysis or early supported discharge could contribute to reducing the financial burden of stroke. Conclusion Extending stroke registers to report individualised data on costs may enhance their potential to support quality improvement and research.

Introduction: The Sentinel Stroke National Audit Programme (SSNAP) is the new national stroke register of England and Wales. It has been designed to harness the power of “Big Data” to produce near real-time data collection, analysis and reporting. Sophisticated data visualization is used to provide customized analytics for clinical teams, administrators, healthcare funders and stroke survivors and carers. Methods: A portfolio of cutting edge data visualisation outputs, including team level slidedecks, performance charts, dashboards , and interactive maps, was produced. Visualisations for patients and the public were co-designed with stroke survivors. Stakeholder feedback regarding accessibility and usefulness of the resources was sought via online polls. Results: Key SSNAP results are made accessible electronically every three months in a range of bespoke graphical formats. Individualised slidedecks and data summaries are produced for every hospital, funding group, and region to enable provider level performance and quality reporting and regional and national benchmarking. Dynamic maps enhance dissemination and use of results. Real time root cause analysis tools help teams identify areas of improvement. Feedback reports unprecedented utility of these resources for clinical teams, funders, regional and national health bodies, patients and the public in identifying areas of good practice and requiring improvements, highlighting variations, and driving change. Conclusion: SSNAP is a potential new model of healthcare quality measurement that uses recent developments in big data analytics and visualization to provide information on stroke care quality that is more useful to stakeholders. Similar approaches could be used in other healthcare settings and populations.