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Schultze A, Martin I, Messina D, Bots S, Belitser S, José Carreras-Martínez J, Correcher-Martinez E, Urchueguía-Fornes A, Martín-Pérez M, García-Poza P, Villalobos F, Pallejà-Millán M, Alberto Bissacco C, Segundo E, Souverein P, Riefolo F, Durán CE, Gini R, Sturkenboom M, Klungel O, Douglas I. A comparison of four self-controlled study designs in an analysis of COVID-19 vaccines and myocarditis using five European databases. Vaccine 2024; 42:3039-3048. [PMID: 38580517 DOI: 10.1016/j.vaccine.2024.03.043] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/16/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION The aim of this study was to assess the possible extent of bias due to violation of a core assumption (event-dependent exposures) when using self-controlled designs to analyse the association between COVID-19 vaccines and myocarditis. METHODS We used data from five European databases (Spain: BIFAP, FISABIO VID, and SIDIAP; Italy: ARS-Tuscany; England: CPRD Aurum) converted to the ConcePTION Common Data Model. Individuals who experienced both myocarditis and were vaccinated against COVID-19 between 1 September 2020 and the end of data availability in each country were included. We compared a self-controlled risk interval study (SCRI) using a pre-vaccination control window, an SCRI using a post-vaccination control window, a standard SCCS and an extension of the SCCS designed to handle violations of the assumption of event-dependent exposures. RESULTS We included 1,757 cases of myocarditis. For analyses of the first dose of the Pfizer vaccine, to which all databases contributed information, we found results consistent with a null effect in both of the SCRI and extended SCCS, but some indication of a harmful effect in a standard SCCS. For the second dose, we found evidence of a harmful association for all study designs, with relatively similar effect sizes (SCRI pre = 1.99, 1.40 - 2.82; SCRI post 2.13, 95 %CI - 1.43, 3.18; standard SCCS 1.79, 95 %CI 1.31 - 2.44, extended SCCS 1.52, 95 %CI = 1.08 - 2.15). Adjustment for calendar time did not change these conclusions. Findings using all designs were also consistent with a harmful effect following a second dose of the Moderna vaccine. CONCLUSIONS In the context of the known association between COVID-19 vaccines and myocarditis, we have demonstrated that two forms of SCRI and two forms of SCCS led to largely comparable results, possibly because of limited violation of the assumption of event-dependent exposures.
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Affiliation(s)
- Anna Schultze
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Ivonne Martin
- Department of Data Science and Biostatistics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Davide Messina
- Agenzia Regionale di Sanità (ARS), Florence, Toscana, Italy
| | - Sophie Bots
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Svetlana Belitser
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Juan José Carreras-Martínez
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO - Public Health), Valencia, Spain; CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Elisa Correcher-Martinez
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO - Public Health), Valencia, Spain; CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Arantxa Urchueguía-Fornes
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO - Public Health), Valencia, Spain; CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Mar Martín-Pérez
- Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | | | - Felipe Villalobos
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Meritxell Pallejà-Millán
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Carlo Alberto Bissacco
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Elena Segundo
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Patrick Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Fabio Riefolo
- Teamit Institute, Partnerships, Barcelona Health Hub, Barcelona, Spain
| | - Carlos E Durán
- Department of Data Science and Biostatistics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rosa Gini
- Agenzia Regionale di Sanità (ARS), Florence, Toscana, Italy
| | - Miriam Sturkenboom
- Department of Data Science and Biostatistics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Olaf Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Ian Douglas
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Schultze A, Tazare J. The role of programming code sharing in improving the transparency of medical research. BMJ 2023; 383:2402. [PMID: 37848206 DOI: 10.1136/bmj.p2402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Affiliation(s)
- Anna Schultze
- London School of Hygiene and Tropical Medicine, London, UK
| | - John Tazare
- London School of Hygiene and Tropical Medicine, London, UK
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Hulme WJ, Williamson E, Horne EMF, Green A, McDonald HI, Walker AJ, Curtis HJ, Morton CE, MacKenna B, Croker R, Mehrkar A, Bacon S, Evans D, Inglesby P, Davy S, Bhaskaran K, Schultze A, Rentsch CT, Tomlinson L, Douglas IJ, Evans SJW, Smeeth L, Palmer T, Goldacre B, Hernán MA, Sterne JAC. Challenges in Estimating the Effectiveness of COVID-19 Vaccination Using Observational Data. Ann Intern Med 2023; 176:685-693. [PMID: 37126810 PMCID: PMC10152408 DOI: 10.7326/m21-4269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
The COVID-19 vaccines were developed and rigorously evaluated in randomized trials during 2020. However, important questions, such as the magnitude and duration of protection, their effectiveness against new virus variants, and the effectiveness of booster vaccination, could not be answered by randomized trials and have therefore been addressed in observational studies. Analyses of observational data can be biased because of confounding and because of inadequate design that does not consider the evolution of the pandemic over time and the rapid uptake of vaccination. Emulating a hypothetical "target trial" using observational data assembled during vaccine rollouts can help manage such potential sources of bias. This article describes 2 approaches to target trial emulation. In the sequential approach, on each day, eligible persons who have not yet been vaccinated are matched to a vaccinated person. The single-trial approach sets a single baseline at the start of the rollout and considers vaccination as a time-varying variable. The nature of the confounding depends on the analysis strategy: Estimating "per-protocol" effects (accounting for vaccination of initially unvaccinated persons after baseline) may require adjustment for both baseline and "time-varying" confounders. These issues are illustrated by using observational data from 2 780 931 persons in the United Kingdom aged 70 years or older to estimate the effect of a first dose of a COVID-19 vaccine. Addressing the issues discussed in this article should help authors of observational studies provide robust evidence to guide clinical and policy decisions.
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Affiliation(s)
- William J Hulme
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Elizabeth Williamson
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Elsie M F Horne
- Population Health Sciences, University of Bristol, Bristol, United Kingdom (E.M.F.H., T.P.)
| | - Amelia Green
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Helen I McDonald
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Alex J Walker
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Helen J Curtis
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Caroline E Morton
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Brian MacKenna
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Richard Croker
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Amir Mehrkar
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Seb Bacon
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - David Evans
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Peter Inglesby
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Simon Davy
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Krishnan Bhaskaran
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Anna Schultze
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Christopher T Rentsch
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Laurie Tomlinson
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Ian J Douglas
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Stephen J W Evans
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London, United Kingdom (E.W., H.I.M., K.B., A.S., C.T.R., L.T., I.J.D., S.J.W.E., L.S.)
| | - Tom Palmer
- Population Health Sciences, University of Bristol, Bristol, United Kingdom (E.M.F.H., T.P.)
| | - Ben Goldacre
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (W.J.H., A.G., A.J.W., H.J.C., C.E.M., B.M., R.C., A.M., S.B., D.E., P.I., S.D., B.G.)
| | - Miguel A Hernán
- Department of Epidemiology, Department of Biostatistics, and CAUSALab, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (M.A.H.)
| | - Jonathan A C Sterne
- Population Health Sciences, University of Bristol; NIHR Bristol Biomedical Research Centre; and Health Data Research UK South West Better Care Partnership, Bristol, United Kingdom (J.A.C.S.)
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4
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Wing K, Grint DJ, Mathur R, Gibbs HP, Hickman G, Nightingale E, Schultze A, Forbes H, Nafilyan V, Bhaskaran K, Williamson E, House T, Pellis L, Herrett E, Gautam N, Curtis HJ, Rentsch CT, Wong AYS, MacKenna B, Mehrkar A, Bacon S, Douglas IJ, Evans SJW, Tomlinson L, Goldacre B, Eggo RM. Association between household composition and severe COVID-19 outcomes in older people by ethnicity: an observational cohort study using the OpenSAFELY platform. Int J Epidemiol 2022; 51:1745-1760. [PMID: 35962974 PMCID: PMC9384728 DOI: 10.1093/ije/dyac158] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/22/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Ethnic differences in the risk of severe COVID-19 may be linked to household composition. We quantified the association between household composition and risk of severe COVID-19 by ethnicity for older individuals. METHODS With the approval of NHS England, we analysed ethnic differences in the association between household composition and severe COVID-19 in people aged 67 or over in England. We defined households by number of age-based generations living together, and used multivariable Cox regression stratified by location and wave of the pandemic and accounted for age, sex, comorbidities, smoking, obesity, housing density and deprivation. We included 2 692 223 people over 67 years in Wave 1 (1 February 2020-31 August 2020) and 2 731 427 in Wave 2 (1 September 2020-31 January 2021). RESULTS Multigenerational living was associated with increased risk of severe COVID-19 for White and South Asian older people in both waves [e.g. Wave 2, 67+ living with three other generations vs 67+-year-olds only: White hazard ratio (HR) 1.61 95% CI 1.38-1.87, South Asian HR 1.76 95% CI 1.48-2.10], with a trend for increased risks of severe COVID-19 with increasing generations in Wave 2. There was also an increased risk of severe COVID-19 in Wave 1 associated with living alone for White (HR 1.35 95% CI 1.30-1.41), South Asian (HR 1.47 95% CI 1.18-1.84) and Other (HR 1.72 95% CI 0.99-2.97) ethnicities, an effect that persisted for White older people in Wave 2. CONCLUSIONS Both multigenerational living and living alone were associated with severe COVID-19 in older adults. Older South Asian people are over-represented within multigenerational households in England, especially in the most deprived settings, whereas a substantial proportion of White older people live alone. The number of generations in a household, number of occupants, ethnicity and deprivation status are important considerations in the continued roll-out of COVID-19 vaccination and targeting of interventions for future pandemics.
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Affiliation(s)
- Kevin Wing
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Daniel J Grint
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Hamish P Gibbs
- Department of Geography, University College London, London, UK
| | - George Hickman
- The DataLab, University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Emily Nightingale
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet Forbes
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Vahé Nafilyan
- Health Modelling Hub, Office of National Statistics, Newport, UK
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas House
- Department of Mathematics, University of Manchester, Manchester, UK
| | - Lorenzo Pellis
- Department of Mathematics, University of Manchester, Manchester, UK
| | - Emily Herrett
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Nileesa Gautam
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Aetion Inc, Boston, USA
| | - Helen J Curtis
- The DataLab, University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Angel Y S Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Brian MacKenna
- The DataLab, University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Amir Mehrkar
- The DataLab, University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Seb Bacon
- The DataLab, University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen J W Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Rosalind M Eggo
- The DataLab, University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
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Bots SH, Riera-Arnau J, Belitser SV, Messina D, Aragón M, Alsina E, Douglas IJ, Durán CE, García-Poza P, Gini R, Herings RMC, Huerta C, Sisay MM, Martín-Pérez M, Martin I, Overbeek JA, Paoletti O, Pallejà-Millán M, Schultze A, Souverein P, Swart KMA, Villalobos F, Klungel OH, Sturkenboom MCJM. Myocarditis and pericarditis associated with SARS-CoV-2 vaccines: A population-based descriptive cohort and a nested self-controlled risk interval study using electronic health care data from four European countries. Front Pharmacol 2022; 13:1038043. [PMID: 36506571 PMCID: PMC9730238 DOI: 10.3389/fphar.2022.1038043] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Estimates of the association between COVID-19 vaccines and myo-/pericarditis risk vary widely across studies due to scarcity of events, especially in age- and sex-stratified analyses. Methods: Population-based cohort study with nested self-controlled risk interval (SCRI) using healthcare data from five European databases. Individuals were followed from 01/01/2020 until end of data availability (31/12/2021 latest). Outcome was first myo-/pericarditis diagnosis. Exposures were first and second dose of Pfizer, AstraZeneca, Moderna, and Janssen COVID-19 vaccines. Baseline incidence rates (IRs), and vaccine- and dose-specific IRs and rate differences were calculated from the cohort The SCRI calculated calendar time-adjusted IR ratios (IRR), using a 60-day pre-vaccination control period and dose-specific 28-day risk windows. IRRs were pooled using random effects meta-analysis. Findings: Over 35 million individuals (49·2% women, median age 39-49 years) were included, of which 57·4% received at least one COVID-19 vaccine dose. Baseline incidence of myocarditis was low. Myocarditis IRRs were elevated after vaccination in those aged < 30 years, after both Pfizer vaccine doses (IRR = 3·3, 95%CI 1·2-9.4; 7·8, 95%CI 2·6-23·5, respectively) and Moderna vaccine dose 2 (IRR = 6·1, 95%CI 1·1-33·5). An effect of AstraZeneca vaccine dose 2 could not be excluded (IRR = 2·42, 95%CI 0·96-6·07). Pericarditis was not associated with vaccination. Interpretation: mRNA-based COVID-19 vaccines and potentially AstraZeneca are associated with increased myocarditis risk in younger individuals, although absolute incidence remains low. More data on children (≤ 11 years) are needed.
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Affiliation(s)
- Sophie H. Bots
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Judit Riera-Arnau
- Department of Datascience and Biostatistics, Julius Center for Health Sciences and Primary Health, University Medical Center Utrecht, Utrecht, Netherlands,Clinical Pharmacology Service, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Svetlana V. Belitser
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | | | - Maria Aragón
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Ema Alsina
- Department of Datascience and Biostatistics, Julius Center for Health Sciences and Primary Health, University Medical Center Utrecht, Utrecht, Netherlands,Clinical Pharmacology Service, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ian J. Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Carlos E. Durán
- Department of Datascience and Biostatistics, Julius Center for Health Sciences and Primary Health, University Medical Center Utrecht, Utrecht, Netherlands,Clinical Pharmacology Service, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Rosa Gini
- Agenzia Regionale di Sanitá, Florence, Toscana, Italy
| | | | - Consuelo Huerta
- Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Malede Mequanent Sisay
- Department of Datascience and Biostatistics, Julius Center for Health Sciences and Primary Health, University Medical Center Utrecht, Utrecht, Netherlands,Clinical Pharmacology Service, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Martín-Pérez
- Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Ivonne Martin
- Department of Datascience and Biostatistics, Julius Center for Health Sciences and Primary Health, University Medical Center Utrecht, Utrecht, Netherlands,Clinical Pharmacology Service, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Olga Paoletti
- Agenzia Regionale di Sanitá, Florence, Toscana, Italy
| | - Meritxell Pallejà-Millán
- Unitat de Suport a la Recerca Tarragona-Reus, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Patrick Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | | | - Felipe Villalobos
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Olaf H. Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Miriam C. J. M. Sturkenboom
- Department of Datascience and Biostatistics, Julius Center for Health Sciences and Primary Health, University Medical Center Utrecht, Utrecht, Netherlands,Clinical Pharmacology Service, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain,*Correspondence: Miriam C. J. M. Sturkenboom,
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Zheng B, Green ACA, Tazare J, Curtis HJ, Fisher L, Nab L, Schultze A, Mahalingasivam V, Parker EPK, Hulme WJ, Bacon SCJ, DeVito NJ, Bates C, Evans D, Inglesby P, Drysdale H, Davy S, Cockburn J, Morton CE, Hickman G, Ward T, Smith RM, Parry J, Hester F, Harper S, Mehrkar A, Eggo RM, Walker AJ, Evans SJW, Douglas IJ, MacKenna B, Goldacre B, Tomlinson LA. Comparative effectiveness of sotrovimab and molnupiravir for prevention of severe covid-19 outcomes in patients in the community: observational cohort study with the OpenSAFELY platform. BMJ 2022; 379:e071932. [PMID: 36384890 PMCID: PMC9667468 DOI: 10.1136/bmj-2022-071932] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the effectiveness of sotrovimab (a neutralising monoclonal antibody) with molnupiravir (an antiviral) in preventing severe outcomes of covid-19 in adult patients infected with SARS-CoV-2 in the community and at high risk of severe outcomes from covid-19. DESIGN Observational cohort study with the OpenSAFELY platform. SETTING With the approval of NHS England, a real world cohort study was conducted with the OpenSAFELY-TPP platform (a secure, transparent, open source software platform for analysis of NHS electronic health records), and patient level electronic health record data were obtained from 24 million people registered with a general practice in England that uses TPP software. The primary care data were securely linked with data on SARS-CoV-2 infection and treatments, hospital admission, and death, over a period when both drug treatments were frequently prescribed in community settings. PARTICIPANTS Adult patients with covid-19 in the community at high risk of severe outcomes from covid-19, treated with sotrovimab or molnupiravir from 16 December 2021. INTERVENTIONS Sotrovimab or molnupiravir given in the community by covid-19 medicine delivery units. MAIN OUTCOME MEASURES Admission to hospital with covid-19 (ie, with covid-19 as the primary diagnosis) or death from covid-19 (ie, with covid-19 as the underlying or contributing cause of death) within 28 days of the start of treatment. RESULTS Between 16 December 2021 and 10 February 2022, 3331 and 2689 patients were treated with sotrovimab and molnupiravir, respectively, with no substantial differences in baseline characteristics. Mean age of all 6020 patients was 52 (standard deviation 16) years; 59% were women, 89% were white, and 88% had received three or more covid-19 vaccinations. Within 28 days of the start of treatment, 87 (1.4%) patients were admitted to hospital or died of infection from SARS-CoV-2 (32 treated with sotrovimab and 55 with molnupiravir). Cox proportional hazards models stratified by area showed that after adjusting for demographic information, high risk cohort categories, vaccination status, calendar time, body mass index, and other comorbidities, treatment with sotrovimab was associated with a substantially lower risk than treatment with molnupiravir (hazard ratio 0.54, 95% confidence interval 0.33 to 0.88, P=0.01). Consistent results were found from propensity score weighted Cox models (0.50, 0.31 to 0.81, P=0.005) and when restricted to people who were fully vaccinated (0.53, 0.31 to 0.90, P=0.02). No substantial effect modifications by other characteristics were detected (all P values for interaction >0.10). The findings were similar in an exploratory analysis of patients treated between 16 February and 1 May 2022 when omicron BA.2 was the predominant variant in England. CONCLUSIONS In routine care of adult patients in England with covid-19 in the community, at high risk of severe outcomes from covid-19, those who received sotrovimab were at lower risk of severe outcomes of covid-19 than those treated with molnupiravir.
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Affiliation(s)
- Bang Zheng
- London School of Hygiene and Tropical Medicine, London, UK
| | - Amelia C A Green
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John Tazare
- London School of Hygiene and Tropical Medicine, London, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louis Fisher
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Linda Nab
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Schultze
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sebastian C J Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom Ward
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rebecca M Smith
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Ian J Douglas
- London School of Hygiene and Tropical Medicine, London, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Grint DJ, Wing K, Houlihan C, Gibbs HP, Evans SJW, Williamson E, McDonald HI, Bhaskaran K, Evans D, Walker AJ, Hickman G, Nightingale E, Schultze A, Rentsch CT, Bates C, Cockburn J, Curtis HJ, Morton CE, Bacon S, Davy S, Wong AYS, Mehrkar A, Tomlinson L, Douglas IJ, Mathur R, MacKenna B, Ingelsby P, Croker R, Parry J, Hester F, Harper S, DeVito NJ, Hulme W, Tazare J, Smeeth L, Goldacre B, Eggo RM. Severity of Severe Acute Respiratory System Coronavirus 2 (SARS-CoV-2) Alpha Variant (B.1.1.7) in England. Clin Infect Dis 2022; 75:e1120-e1127. [PMID: 34487522 PMCID: PMC8522415 DOI: 10.1093/cid/ciab754] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [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: 07/19/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) alpha variant (B.1.1.7) is associated with higher transmissibility than wild-type virus, becoming the dominant variant in England by January 2021. We aimed to describe the severity of the alpha variant in terms of the pathway of disease from testing positive to hospital admission and death. METHODS With the approval of NHS England, we linked individual-level data from primary care with SARS-CoV-2 community testing, hospital admission, and Office for National Statistics all-cause death data. We used testing data with S-gene target failure as a proxy for distinguishing alpha and wild-type cases, and stratified Cox proportional hazards regression to compare the relative severity of alpha cases with wild-type diagnosed from 16 November 2020 to 11 January 2021. RESULTS Using data from 185 234 people who tested positive for SARS-CoV-2 in the community (alpha = 93 153; wild-type = 92 081), in fully adjusted analysis accounting for individual-level demographics and comorbidities as well as regional variation in infection incidence, we found alpha associated with 73% higher hazards of all-cause death (adjusted hazard ratio [aHR]: 1.73; 95% confidence interval [CI]: 1.41-2.13; P < .0001) and 62% higher hazards of hospital admission (1.62; 1.48-1.78; P < .0001) compared with wild-type virus. Among patients already admitted to the intensive care unit, the association between alpha and increased all-cause mortality was smaller and the CI included the null (aHR: 1.20; 95% CI: .74-1.95; P = .45). CONCLUSIONS The SARS-CoV-2 alpha variant is associated with an increased risk of both hospitalization and mortality than wild-type virus.
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Affiliation(s)
- Daniel J Grint
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kevin Wing
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Catherine Houlihan
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Hamish P Gibbs
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen J W Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Emily Nightingale
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Angel Y S Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Peter Ingelsby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Will Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - John Tazare
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rosalind M Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Morton C, Devito N, Morley J, Dillingham I, Schultze A, Bacon S, Inglesby P, Maude S, Goldacre B. Software development skills for health data researchers. BMJ Health Care Inform 2022; 29:bmjhci-2021-100488. [PMID: 35944928 PMCID: PMC9367192 DOI: 10.1136/bmjhci-2021-100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Walker JL, Schultze A, Tazare J, Tamborska A, Singh B, Donegan K, Stowe J, Morton CE, Hulme WJ, Curtis HJ, Williamson EJ, Mehrkar A, Eggo RM, Rentsch CT, Mathur R, Bacon S, Walker AJ, Davy S, Evans D, Inglesby P, Hickman G, MacKenna B, Tomlinson L, Ca Green A, Fisher L, Cockburn J, Parry J, Hester F, Harper S, Bates C, Evans SJ, Solomon T, Andrews NJ, Douglas IJ, Goldacre B, Smeeth L, McDonald HI. Safety of COVID-19 vaccination and acute neurological events: A self-controlled case series in England using the OpenSAFELY platform. Vaccine 2022; 40:4479-4487. [PMID: 35715350 PMCID: PMC9170533 DOI: 10.1016/j.vaccine.2022.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 01/14/2022] [Revised: 05/20/2022] [Accepted: 06/02/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION We investigated the potential association of COVID-19 vaccination with three acute neurological events: Guillain-Barré syndrome (GBS), transverse myelitis and Bell's palsy. METHODS With the approval of NHS England we analysed primary care data from >17 million patients in England linked to emergency care, hospital admission and mortality records in the OpenSAFELY platform. Separately for each vaccine brand, we used a self-controlled case series design to estimate the incidence rate ratio for each outcome in the period following vaccination (4-42 days for GBS, 4-28 days for transverse myelitis and Bell's palsy) compared to a within-person baseline, using conditional Poisson regression. RESULTS Among 7,783,441 ChAdOx1 vaccinees, there was an increased rate of GBS (N = 517; incidence rate ratio 2·85; 95% CI2·33-3·47) and Bell's palsy (N = 5,350; 1·39; 1·27-1·53) following a first dose of ChAdOx1 vaccine, corresponding to 11.0 additional cases of GBS and 17.9 cases of Bell's palsy per 1 million vaccinees if causal. For GBS this applied to the first, but not the second, dose. There was no clear evidence of an association of ChAdOx1 vaccination with transverse myelitis (N = 199; 1·51; 0·96-2·37). Among 5,729,152 BNT162b2 vaccinees, there was no evidence of any association with GBS (N = 283; 1·09; 0·75-1·57), transverse myelitis (N = 109; 1·62; 0·86-3·03) or Bell's palsy (N = 3,609; 0·89; 0·76-1·03). Among 255,446 mRNA-1273 vaccine recipients there was no evidence of an association with Bell's palsy (N = 78; 0·88, 0·32-2·42). CONCLUSIONS COVID-19 vaccines save lives, but it is important to understand rare adverse events. We observed a short-term increased rate of Guillain-Barré syndrome and Bell's palsy after first dose of ChAdOx1 vaccine. The absolute risk, assuming a causal effect attributable to vaccination, was low.
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Affiliation(s)
- Jemma L Walker
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation; UK Health Security Agency, 61 Colindale Ave, London NW9 5EQ, UK
| | - Anna Schultze
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - John Tazare
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Arina Tamborska
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - Bhagteshwar Singh
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, UK; Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - Katherine Donegan
- Medicines and Healthcare products Regulatory Agency (MHRA), 10 South Colonnade, Canary Wharf, London E14 4PU, UK
| | - Julia Stowe
- UK Health Security Agency, 61 Colindale Ave, London NW9 5EQ, UK
| | - Caroline E Morton
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - William J Hulme
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Helen J Curtis
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Elizabeth J Williamson
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Amir Mehrkar
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Rosalind M Eggo
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Christopher T Rentsch
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Rohini Mathur
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Sebastian Bacon
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Alex J Walker
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Simon Davy
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - David Evans
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Peter Inglesby
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - George Hickman
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Brian MacKenna
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Laurie Tomlinson
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Amelia Ca Green
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Louis Fisher
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Jonathan Cockburn
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - John Parry
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Frank Hester
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Sam Harper
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Christopher Bates
- OpenSAFELY Collaborative, UK; TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Stephen Jw Evans
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Tom Solomon
- NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - Nick J Andrews
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation; UK Health Security Agency, 61 Colindale Ave, London NW9 5EQ, UK
| | - Ian J Douglas
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Ben Goldacre
- OpenSAFELY Collaborative, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG, UK
| | - Liam Smeeth
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation
| | - Helen I McDonald
- OpenSAFELY Collaborative, UK; London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; NIHR Health Protection Research Unit (HPRU) in Vaccines and Immunisation.
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Hulme WJ, Williamson EJ, Green ACA, Bhaskaran K, McDonald HI, Rentsch CT, Schultze A, Tazare J, Curtis HJ, Walker AJ, Tomlinson LA, Palmer T, Horne EMF, MacKenna B, Morton CE, Mehrkar A, Morley J, Fisher L, Bacon SCJ, Evans D, Inglesby P, Hickman G, Davy S, Ward T, Croker R, Eggo RM, Wong AYS, Mathur R, Wing K, Forbes H, Grint DJ, Douglas IJ, Evans SJW, Smeeth L, Bates C, Cockburn J, Parry J, Hester F, Harper S, Sterne JAC, Hernán MA, Goldacre B. Comparative effectiveness of ChAdOx1 versus BNT162b2 covid-19 vaccines in health and social care workers in England: cohort study using OpenSAFELY. BMJ 2022; 378:e068946. [PMID: 35858680 PMCID: PMC9295078 DOI: 10.1136/bmj-2021-068946] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Accepted: 06/11/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare the effectiveness of the BNT162b2 mRNA (Pfizer-BioNTech) and the ChAdOx1 (Oxford-AstraZeneca) covid-19 vaccines against infection and covid-19 disease in health and social care workers. DESIGN Cohort study, emulating a comparative effectiveness trial, on behalf of NHS England. SETTING Linked primary care, hospital, and covid-19 surveillance records available within the OpenSAFELY-TPP research platform, covering a period when the SARS-CoV-2 Alpha variant was dominant. PARTICIPANTS 317 341 health and social care workers vaccinated between 4 January and 28 February 2021, registered with a general practice using the TPP SystmOne clinical information system in England, and not clinically extremely vulnerable. INTERVENTIONS Vaccination with either BNT162b2 or ChAdOx1 administered as part of the national covid-19 vaccine roll-out. MAIN OUTCOME MEASURES Recorded SARS-CoV-2 positive test, or covid-19 related attendance at an accident and emergency (A&E) department or hospital admission occurring within 20 weeks of receipt of the first vaccine dose. RESULTS Over the duration of 118 771 person-years of follow-up there were 6962 positive SARS-CoV-2 tests, 282 covid-19 related A&E attendances, and 166 covid-19 related hospital admissions. The cumulative incidence of each outcome was similar for both vaccines during the first 20 weeks after vaccination. The cumulative incidence of recorded SARS-CoV-2 infection 20 weeks after first-dose vaccination with BNT162b2 was 21.7 per 1000 people (95% confidence interval 20.9 to 22.4) and with ChAdOx1 was 23.7 (21.8 to 25.6), representing a difference of 2.04 per 1000 people (0.04 to 4.04). The difference in the cumulative incidence per 1000 people of covid-19 related A&E attendance at 20 weeks was 0.06 per 1000 people (95% CI -0.31 to 0.43). For covid-19 related hospital admission, this difference was 0.11 per 1000 people (-0.22 to 0.44). CONCLUSIONS In this cohort of healthcare workers where we would not anticipate vaccine type to be related to health status, we found no substantial differences in the incidence of SARS-CoV-2 infection or covid-19 disease up to 20 weeks after vaccination. Incidence dropped sharply at 3-4 weeks after vaccination, and there were few covid-19 related hospital attendance and admission events after this period. This is in line with expected onset of vaccine induced immunity and suggests strong protection against Alpha variant covid-19 disease for both vaccines in this relatively young and healthy population of healthcare workers.
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Affiliation(s)
- William J Hulme
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | | | - Amelia C A Green
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | | | - Helen I McDonald
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Anna Schultze
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - John Tazare
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Helen J Curtis
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Alex J Walker
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | | | - Tom Palmer
- MRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
| | - Elsie M F Horne
- Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
- NIHR Bristol, Biomedical Research Centre, Bristol BS8 2BN, UK
| | - Brian MacKenna
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Caroline E Morton
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Amir Mehrkar
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Jessica Morley
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Louis Fisher
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Sebastian C J Bacon
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - David Evans
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Peter Inglesby
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - George Hickman
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Simon Davy
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Tom Ward
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Richard Croker
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Rosalind M Eggo
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Angel Y S Wong
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Rohini Mathur
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Kevin Wing
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Harriet Forbes
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Daniel J Grint
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Ian J Douglas
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Chris Bates
- TPP, TPP House, Horsforth, Leeds LS18 5PX, UK
| | | | - John Parry
- TPP, TPP House, Horsforth, Leeds LS18 5PX, UK
| | | | - Sam Harper
- TPP, TPP House, Horsforth, Leeds LS18 5PX, UK
| | - Jonathan A C Sterne
- Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
- NIHR Bristol, Biomedical Research Centre, Bristol BS8 2BN, UK
- Health Data Research UK South West
| | - Miguel A Hernán
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Ben Goldacre
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
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11
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Andrews C, Schultze A, Curtis H, Hulme W, Tazare J, Evans S, Mehrkar A, Bacon S, Hickman G, Bates C, Parry J, Hester F, Harper S, Cockburn J, Evans D, Ward T, Davy S, Inglesby P, Goldacre B, MacKenna B, Tomlinson L, Walker A. OpenSAFELY: Representativeness of electronic health record platform OpenSAFELY-TPP data compared to the population of England. Wellcome Open Res 2022; 7:191. [PMID: 35966958 PMCID: PMC9346309 DOI: 10.12688/wellcomeopenres.18010.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 12/11/2022] Open
Abstract
Background: Since its inception in March 2020, data from the OpenSAFELY-TPP electronic health record platform has been used for more than 20 studies relating to the global COVID-19 emergency. OpenSAFELY-TPP data is derived from practices in England using SystmOne software, and has been used for the majority of these studies. We set out to investigate the representativeness of OpenSAFELY-TPP data by comparing it to national population estimates. Methods: With the approval of NHS England, we describe the age, sex, Index of Multiple Deprivation and ethnicity of the OpenSAFELY-TPP population compared to national estimates from the Office for National Statistics. The five leading causes of death occurring between the 1st January 2020 and the 31st December 2020 were also compared to deaths registered in England during the same period. Results: Despite regional variations, TPP is largely representative of the general population of England in terms of IMD (all within 1.1 percentage points), age, sex (within 0.1 percentage points), ethnicity and causes of death. The proportion of the five leading causes of death is broadly similar to those reported by ONS (all within 1 percentage point). Conclusions: Data made available via OpenSAFELY-TPP is broadly representative of the English population. Users of OpenSAFELY must consider the issues of representativeness, generalisability and external validity associated with using TPP data for health research. Although the coverage of TPP practices varies regionally across England, TPP registered patients are generally representative of the English population as a whole in terms of key demographic characteristics.
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Affiliation(s)
- Colm Andrews
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Anna Schultze
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Helen Curtis
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - William Hulme
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - John Tazare
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Stephen Evans
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Amir Mehrkar
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Sebastian Bacon
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - George Hickman
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | | | - John Parry
- TPP, TPP House, Leeds, Yorkshire, LS18 5PX, UK
| | | | - Sam Harper
- TPP, TPP House, Leeds, Yorkshire, LS18 5PX, UK
| | | | - David Evans
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Tom Ward
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Simon Davy
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Peter Inglesby
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Ben Goldacre
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Brian MacKenna
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
| | - Laurie Tomlinson
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Alex Walker
- Bennett Institute of Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxon, OX26GG,, UK
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12
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Green A, Curtis H, Hulme W, Williamson E, McDonald H, Bhaskaran K, Rentsch C, Schultze A, MacKenna B, Mahalingasivam V, Tomlinson L, Walker A, Fisher L, Massey J, Andrews C, Hopcroft L, Morton C, Croker R, Morley J, Mehrkar A, Bacon S, Evans D, Inglesby P, Hickman G, Ward T, Davy S, Mathur R, Tazare J, Eggo R, Wing K, Wong A, Forbes H, Bates C, Cockburn J, Parry J, Hester F, Harper S, Douglas I, Evans S, Smeeth L, Goldacre B. Describing the population experiencing COVID-19 vaccine breakthrough following second vaccination in England: a cohort study from OpenSAFELY. BMC Med 2022; 20:243. [PMID: 35791013 PMCID: PMC9255436 DOI: 10.1186/s12916-022-02422-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/30/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND While the vaccines against COVID-19 are highly effective, COVID-19 vaccine breakthrough is possible despite being fully vaccinated. With SARS-CoV-2 variants still circulating, describing the characteristics of individuals who have experienced COVID-19 vaccine breakthroughs could be hugely important in helping to determine who may be at greatest risk. METHODS With the approval of NHS England, we conducted a retrospective cohort study using routine clinical data from the OpenSAFELY-TPP database of fully vaccinated individuals, linked to secondary care and death registry data and described the characteristics of those experiencing COVID-19 vaccine breakthroughs. RESULTS As of 1st November 2021, a total of 15,501,550 individuals were identified as being fully vaccinated against COVID-19, with a median follow-up time of 149 days (IQR: 107-179). From within this population, a total of 579,780 (<4%) individuals reported a positive SARS-CoV-2 test. For every 1000 years of patient follow-up time, the corresponding incidence rate (IR) was 98.06 (95% CI 97.93-98.19). There were 28,580 COVID-19-related hospital admissions, 1980 COVID-19-related critical care admissions and 6435 COVID-19-related deaths; corresponding IRs 4.77 (95% CI 4.74-4.80), 0.33 (95% CI 0.32-0.34) and 1.07 (95% CI 1.06-1.09), respectively. The highest rates of breakthrough COVID-19 were seen in those in care homes and in patients with chronic kidney disease, dialysis, transplant, haematological malignancy or who were immunocompromised. CONCLUSIONS While the majority of COVID-19 vaccine breakthrough cases in England were mild, some differences in rates of breakthrough cases have been identified in several clinical groups. While it is important to note that these findings are simply descriptive and cannot be used to answer why certain groups have higher rates of COVID-19 breakthrough than others, the emergence of the Omicron variant of COVID-19 coupled with the number of positive SARS-CoV-2 tests still occurring is concerning and as numbers of fully vaccinated (and boosted) individuals increases and as follow-up time lengthens, so too will the number of COVID-19 breakthrough cases. Additional analyses, to assess vaccine waning and rates of breakthrough COVID-19 between different variants, aimed at identifying individuals at higher risk, are needed.
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Affiliation(s)
- Amelia Green
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Helen Curtis
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - William Hulme
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Elizabeth Williamson
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Helen McDonald
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Krishnan Bhaskaran
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Christopher Rentsch
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Anna Schultze
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | | | - Laurie Tomlinson
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Alex Walker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Louis Fisher
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Jon Massey
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Colm Andrews
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Lisa Hopcroft
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Caroline Morton
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard Croker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Jessica Morley
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Seb Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - David Evans
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Peter Inglesby
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - George Hickman
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Tom Ward
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Simon Davy
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Rohini Mathur
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - John Tazare
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rosalind Eggo
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kevin Wing
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Angel Wong
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Harriet Forbes
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Chris Bates
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | | | - John Parry
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Frank Hester
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Sam Harper
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Ian Douglas
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Stephen Evans
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK.
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Wong AY, Tomlinson L, Brown JP, Elson W, Walker AJ, Schultze A, Morton CE, Evans D, Inglesby P, MacKenna B, Bhaskaran K, Rentsch CT, Powell E, Williamson E, Croker R, Bacon S, Hulme W, Bates C, Curtis HJ, Mehrkar A, Cockburn J, McDonald HI, Mathur R, Wing K, Forbes H, Eggo RM, Evans SJ, Smeeth L, Goldacre B, Douglas IJ. Association between oral anticoagulants and COVID-19-related outcomes: a population-based cohort study. Br J Gen Pract 2022; 72:e456-e463. [PMID: 35440465 PMCID: PMC9037187 DOI: 10.3399/bjgp.2021.0689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/08/2021] [Accepted: 02/06/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Early evidence has shown that anticoagulant reduces the risk of thrombotic events in those infected with COVID-19. However, evidence of the role of routinely prescribed oral anticoagulants (OACs) in COVID-19 outcomes is limited. AIM To investigate the association between OACs and COVID-19 outcomes in those with atrial fibrillation and a CHA2DS2-VASc score of 2. DESIGN AND SETTING On behalf of NHS England, a population-based cohort study was conducted. METHOD The study used primary care data and pseudonymously-linked SARS-CoV-2 antigen testing data, hospital admissions, and death records from England. Cox regression was used to estimate hazard ratios (HRs) for COVID-19 outcomes comparing people with current OAC use versus non-use, accounting for age, sex, comorbidities, other medications, deprivation, and general practice. RESULTS Of 71 103 people with atrial fibrillation and a CHA2DS2-VASc score of 2, there were 52 832 current OAC users and 18 271 non-users. No difference in risk of being tested for SARS-CoV-2 was associated with current use (adjusted HR [aHR] 0.99, 95% confidence interval [CI] = 0.95 to 1.04) versus non-use. A lower risk of testing positive for SARS-CoV-2 (aHR 0.77, 95% CI = 0.63 to 0.95) and a marginally lower risk of COVID-19-related death (aHR, 0.74, 95% CI = 0.53 to 1.04) were associated with current use versus non-use. CONCLUSION Among those at low baseline stroke risk, people receiving OACs had a lower risk of testing positive for SARS-CoV-2 and severe COVID-19 outcomes than non-users; this might be explained by a causal effect of OACs in preventing severe COVID-19 outcomes or unmeasured confounding, including more cautious behaviours leading to reduced infection risk.
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Affiliation(s)
- Angel Ys Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Jeremy P Brown
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - William Elson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Emma Powell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | | | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | | | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London and NIHR Health Protection Research Unit (HPRU) in Immunisation, London School of Hygiene and Tropical Medicine, London
| | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Kevin Wing
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | | | - Rosalind M Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Stephen Jw Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London and NIHR Health Protection Research Unit (HPRU) in Immunisation, London School of Hygiene and Tropical Medicine, London
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
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14
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MacKenna B, Kennedy NA, Mehrkar A, Rowan A, Galloway J, Matthewman J, Mansfield KE, Bechman K, Yates M, Brown J, Schultze A, Norton S, Walker AJ, Morton CE, Harrison D, Bhaskaran K, Rentsch CT, Williamson E, Croker R, Bacon S, Hickman G, Ward T, Davy S, Green A, Fisher L, Hulme W, Bates C, Curtis HJ, Tazare J, Eggo RM, Evans D, Inglesby P, Cockburn J, McDonald HI, Tomlinson LA, Mathur R, Wong AYS, Forbes H, Parry J, Hester F, Harper S, Douglas IJ, Smeeth L, Lees CW, Evans SJW, Goldacre B, Smith CH, Langan SM. Risk of severe COVID-19 outcomes associated with immune-mediated inflammatory diseases and immune-modifying therapies: a nationwide cohort study in the OpenSAFELY platform. Lancet Rheumatol 2022; 4:e490-e506. [PMID: 35698725 PMCID: PMC9179144 DOI: 10.1016/s2665-9913(22)00098-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background The risk of severe COVID-19 outcomes in people with immune-mediated inflammatory diseases and on immune-modifying drugs might not be fully mediated by comorbidities and might vary by factors such as ethnicity. We aimed to assess the risk of severe COVID-19 in adults with immune-mediated inflammatory diseases and in those on immune-modifying therapies. Methods We did a cohort study, using OpenSAFELY (an analytics platform for electronic health records) and TPP (a software provider for general practitioners), analysing routinely collected primary care data linked to hospital admission, death, and previously unavailable hospital prescription data. We included people aged 18 years or older on March 1, 2020, who were registered with TPP practices with at least 12 months of primary care records before March, 2020. We used Cox regression (adjusting for confounders and mediators) to estimate hazard ratios (HRs) comparing the risk of COVID-19-related death, critical care admission or death, and hospital admission (from March 1 to Sept 30, 2020) in people with immune-mediated inflammatory diseases compared with the general population, and in people with immune-mediated inflammatory diseases on targeted immune-modifying drugs (eg, biologics) compared with those on standard systemic treatment (eg, methotrexate). Findings We identified 17 672 065 adults; 1 163 438 adults (640 164 [55·0%] women and 523 274 [45·0%] men, and 827 457 [71·1%] of White ethnicity) had immune-mediated inflammatory diseases, and 16 508 627 people (8 215 020 [49·8%] women and 8 293 607 [50·2%] men, and 10 614 096 [64·3%] of White ethnicity) were included as the general population. Of 1 163 438 adults with immune-mediated inflammatory diseases, 19 119 (1·6%) received targeted immune-modifying therapy and 181 694 (15·6%) received standard systemic therapy. Compared with the general population, adults with immune-mediated inflammatory diseases had an increased risk of COVID-19-related death after adjusting for confounders (age, sex, deprivation, and smoking status; HR 1·23, 95% CI 1·20-1·27) and further adjusting for mediators (body-mass index [BMI], cardiovascular disease, diabetes, and current glucocorticoid use; 1·15, 1·11-1·18). Adults with immune-mediated inflammatory diseases also had an increased risk of COVID-19-related critical care admission or death (confounder-adjusted HR 1·24, 95% CI 1·21-1·28; mediator-adjusted 1·16, 1·12-1·19) and hospital admission (confounder-adjusted 1·32, 1·29-1·35; mediator-adjusted 1·20, 1·17-1·23). In post-hoc analyses, the risk of severe COVID-19 outcomes in people with immune-mediated inflammatory diseases was higher in non-White ethnic groups than in White ethnic groups (as it was in the general population). We saw no evidence of increased COVID-19-related death in adults on targeted, compared with those on standard systemic, therapy after adjusting for confounders (age, sex, deprivation, BMI, immune-mediated inflammatory diseases [bowel, joint, and skin], cardiovascular disease, cancer [excluding non-melanoma skin cancer], stroke, and diabetes (HR 1·03, 95% CI 0·80-1·33), and after additionally adjusting for current glucocorticoid use (1·01, 0·78-1·30). There was no evidence of increased COVID-19-related death in adults prescribed tumour necrosis factor inhibitors, interleukin (IL)-12/IL‑23 inhibitors, IL-17 inhibitors, IL-6 inhibitors, or Janus kinase inhibitors compared with those on standard systemic therapy. Rituximab was associated with increased COVID-19-related death (HR 1·68, 95% CI 1·11-2·56), with some attenuation after excluding people with haematological malignancies or organ transplants (1·54, 0·95-2·49). Interpretation COVID-19 deaths and hospital admissions were higher in people with immune-mediated inflammatory diseases. We saw no increased risk of adverse COVID-19 outcomes in those on most targeted immune-modifying drugs for immune-mediated inflammatory diseases compared with those on standard systemic therapy. Funding UK Medical Research Council, NIHR Biomedical Research Centre at King's College London and Guy's and St Thomas' NHS Foundation Trust, and Wellcome Trust.
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Affiliation(s)
- Brian MacKenna
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- IBD Research Group, University of Exeter, Exeter, UK
| | - Amir Mehrkar
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Rowan
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - James Galloway
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Julian Matthewman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kathryn E Mansfield
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Katie Bechman
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Mark Yates
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Jeremy Brown
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sam Norton
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Alex J Walker
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline E Morton
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard Croker
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Seb Bacon
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - George Hickman
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom Ward
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon Davy
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amelia Green
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louis Fisher
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William Hulme
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Helen J Curtis
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John Tazare
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Rosalind M Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Evans
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Laurie A Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Angel Y S Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Harriet Forbes
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlie W Lees
- Centre for Genomics and Experimental Medicine, University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Stephen J W Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ben Goldacre
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Catherine H Smith
- St John's Institute of Dermatology, King's College London, London, UK
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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15
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Cid-Ruzafa J, Lacy BE, Schultze A, Duong M, Lu Y, Raluy-Callado M, Donaldson R, Weissman D, Gómez-Lumbreras A, Ouchi D, Giner-Soriano M, Morros R, Ukah A, Pohl D. Linaclotide utilization and potential for off-label use and misuse in three European countries. Therap Adv Gastroenterol 2022; 15:17562848221100946. [PMID: 35706826 PMCID: PMC9189524 DOI: 10.1177/17562848221100946] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Linaclotide is approved for adults with moderate-to-severe irritable bowel syndrome (IBS) with constipation (IBS-C). Linaclotide is not indicated for weight loss or for patients with inflammatory bowel disease (IBD); it is contraindicated in patients with mechanical bowel obstruction (MBO). Some patients with obesity or eating disorders (ED) may use linaclotide off-label for weight loss or as a laxative. OBJECTIVES To describe the use of linaclotide in clinical practice, including patients with potential for off-label use or misuse. METHODS Post-authorization safety study conducted in three databases from the linaclotide launch date to 2017: the Clinical Practice Research Datalink in the United Kingdom (UK), the Information System for Research in Primary Care database in Spain and the linked Patient, Prescription and Causes of Death Registries in Sweden. Cohorts of patients were identified as having IBS using diagnostic and treatment codes; IBS subtypes were identified using symptoms and treatment codes; patients with obesity, ED, MBO, and IBD were identified using diagnostic codes or body mass index. RESULTS There were 1319, 1981, and 5081 linaclotide users from the United Kingdom, Spain, and Sweden with a median age of 45, 57, and 51 years, respectively; most were females. In the United Kingdom, Spain, and Sweden, respectively: 59.0%, 60.3%, and 31.3% of linaclotide users had an IBS diagnosis recorded, and among those, 68.8%, 61.3%, and 92.7% were classified as IBS-C. The proportions of linaclotide users considered at risk for potential off-label use for weight loss or as a laxative were 17.1%, 29.7%, and 1.7%, and the proportions of users considered at risk of misuse due to a history of MBO or IBD were 3.5%, 4.6%, and 5.7% in the United Kingdom, Spain, and Sweden, respectively. CONCLUSIONS Potential linaclotide off-label use and misuse appears limited, as evidenced by the small sizes of the patient subgroups at risk for off-label use and misuse.
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Affiliation(s)
| | - Brian E. Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | | | | | | | | | - Ainhoa Gómez-Lumbreras
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | - Dan Ouchi
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | - Maria Giner-Soriano
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cerdanyola del Vallès (Barcelona), Spain
| | | | - Daniel Pohl
- Neurogastroenterology and Motility, Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
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16
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Tazare J, Walker AJ, Tomlinson LA, Hickman G, Rentsch CT, Williamson EJ, Bhaskaran K, Evans D, Wing K, Mathur R, Wong AYS, Schultze A, Bacon S, Bates C, Morton CE, Curtis HJ, Nightingale E, McDonald HI, Mehrkar A, Inglesby P, Davy S, MacKenna B, Cockburn J, Hulme WJ, Warren-Gash C, Bhate K, Nitsch D, Powell E, Mulick A, Forbes H, Minassian C, Croker R, Parry J, Hester F, Harper S, Eggo RM, Evans SJW, Smeeth L, Douglas IJ, Goldacre B. Rates of serious clinical outcomes in survivors of hospitalisation with COVID-19 in England: a descriptive cohort study within the OpenSAFELY platform. Wellcome Open Res 2022; 7:142. [PMID: 37362009 PMCID: PMC10285340 DOI: 10.12688/wellcomeopenres.17735.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 03/07/2024] Open
Abstract
Background: Patients surviving hospitalisation for COVID-19 are thought to be at high risk of cardiometabolic and pulmonary complications, but quantification of that risk is limited. We aimed to describe the overall burden of these complications in people after discharge from hospital with COVID-19. Methods: Working on behalf of NHS England, we used linked primary care records, death certificate and hospital data from the OpenSAFELY platform. We constructed three cohorts: patients discharged following hospitalisation with COVID-19, patients discharged following pre-pandemic hospitalisation with pneumonia, and a frequency-matched cohort from the general population in 2019. We studied seven outcomes: deep vein thrombosis (DVT), pulmonary embolism (PE), ischaemic stroke, myocardial infarction (MI), heart failure, AKI and new type 2 diabetes mellitus (T2DM) diagnosis. Absolute rates were measured in each cohort and Fine and Gray models were used to estimate age/sex adjusted subdistribution hazard ratios comparing outcome risk between discharged COVID-19 patients and the two comparator cohorts. Results: Amongst the population of 77,347 patients discharged following hospitalisation with COVID-19, rates for the majority of outcomes peaked in the first month post-discharge, then declined over the following four months. Patients in the COVID-19 population had markedly higher risk of all outcomes compared to matched controls from the 2019 general population. Across the whole study period, the risk of outcomes was more similar when comparing patients discharged with COVID-19 to those discharged with pneumonia in 2019, although COVID-19 patients had higher risk of T2DM (15.2 versus 37.2 [rate per 1,000-person-years for COVID-19 versus pneumonia, respectively]; SHR, 1.46 [95% CI: 1.31 - 1.63]). Conclusions: Risk of cardiometabolic and pulmonary adverse outcomes is markedly raised following discharge from hospitalisation with COVID-19 compared to the general population. However, excess risks were similar to those seen following discharge post-pneumonia. Overall, this suggests a large additional burden on healthcare resources.
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Affiliation(s)
- The OpenSAFELY Collaborative
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
- NIHR Health Protection Research Unit (HPRU) in Immunisation, London, UK
| | - John Tazare
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Alex J. Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | | | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | | | | | | | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Kevin Wing
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Rohini Mathur
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Angel YS. Wong
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Anna Schultze
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Chris Bates
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | | | - Helen J. Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
- NIHR Health Protection Research Unit (HPRU) in Immunisation, London, UK
| | | | | | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | | | - William J. Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | | | - Ketaki Bhate
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Dorothea Nitsch
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Emma Powell
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Amy Mulick
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Harriet Forbes
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | | | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - John Parry
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Frank Hester
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Sam Harper
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Rosalind M. Eggo
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | | | - Liam Smeeth
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Ian J Douglas
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
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17
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Baptiste PJ, Wong AYS, Schultze A, Cunnington M, Mann JFE, Clase C, Leyrat C, Tomlinson LA, Wing K. Effects of ACE inhibitors and angiotensin receptor blockers: protocol for a UK cohort study using routinely collected electronic health records with validation against the ONTARGET trial. BMJ Open 2022; 12:e051907. [PMID: 35260450 PMCID: PMC8905982 DOI: 10.1136/bmjopen-2021-051907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Cardiovascular disease is a leading cause of death globally, responsible for nearly 18 million deaths worldwide in 2017. Medications to reduce the risk of cardiovascular events are prescribed based on evidence from clinical trials which explore treatment effects in an indicated sample of the general population. However, these results may not be fully generalisable because of trial eligibility criteria that generally restrict to younger patients with fewer comorbidities. Therefore, evidence of effectiveness of medications for groups underrepresented in clinical trials such as those aged ≥75 years, from ethnic minority backgrounds or with low kidney function may be limited.Using individual anonymised data from the Ongoing Telmisartan Alone and the Ramipril Global Endpoint Trial (ONTARGET) trial, in collaboration with the original trial investigators, we aim to investigate clinical trial replicability within a real-world setting in the area of cardiovascular disease. If the original trial results are replicable, we will estimate treatment effects and risk in groups underrepresented and excluded from the original clinical trial. METHODS AND ANALYSIS We will develop a cohort analogous to the ONTARGET trial within the Clinical Practice Research Datalink between 1 January 2001 and 31 July 2019 using the trial eligibility criteria and propensity score matching. The primary outcome is a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and hospitalisation for congestive heart failure. If results from the cohort study fall within pre-specified limits, we will expand the cohort to include under represented and excluded groups. ETHICS AND DISSEMINATION Ethical approval has been granted by the London School of Hygiene & Tropical Medicine Ethics Committee (Ref: 22658). The study has been approved by the Independent Scientific Advisory Committee of the UK Medicines and Healthcare Products Regulatory Agency (protocol no. 20_012). Access to the individual patient data from the ONTARGET trial was obtained by the trial investigators. Findings will be submitted to peer-reviewed journals and presented at conferences.
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Affiliation(s)
- Paris J Baptiste
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Angel Y S Wong
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Schultze
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Marianne Cunnington
- Epidemiology, Value & Evidence Outcomes, GlaxoSmithKline Research and Development Welwyn, Stevenage, UK
| | - Johannes F E Mann
- Department of Medicine 4, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Germany
- KfH-Nierenzentrum, München-Schwabing, Germany
| | - Catherine Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Clémence Leyrat
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Wing
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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18
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Schultze A, Nightingale E, Evans D, Hulme W, Rosello A, Bates C, Cockburn J, MacKenna B, Curtis HJ, Morton CE, Croker R, Bacon S, McDonald HI, Rentsch CT, Bhaskaran K, Mathur R, Tomlinson LA, Williamson EJ, Forbes H, Tazare J, Grint D, Walker AJ, Inglesby P, DeVito NJ, Mehrkar A, Hickman G, Davy S, Ward T, Fisher L, Green ACA, Wing K, Wong AYS, McManus R, Parry J, Hester F, Harper S, Evans SJW, Douglas IJ, Smeeth L, Eggo RM, Goldacre B, Leon DA. Mortality among Care Home Residents in England during the first and second waves of the COVID-19 pandemic: an observational study of 4.3 million adults over the age of 65. Lancet Reg Health Eur 2022; 14:100295. [PMID: 35036983 PMCID: PMC8743167 DOI: 10.1016/j.lanepe.2021.100295] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Residents in care homes have been severely impacted by COVID-19. We describe trends in the mortality risk among residents of care homes compared to private homes. METHODS On behalf of NHS England we used OpenSAFELY-TPP to calculate monthly age-standardised risks of death due to all causes and COVID-19 among adults aged >=65 years between 1/2/2019 and 31/03/2021. Care home residents were identified using linkage to Care and Quality Commission data. FINDINGS We included 4,340,648 people aged 65 years or older on the 1st of February 2019, 2.2% of whom were classified as residing in a care or nursing home. Age-standardised mortality risks were approximately 10 times higher among care home residents compared to those in private housing in February 2019: comparative mortality figure (CMF) = 10.59 (95%CI = 9.51, 11.81) among women, and 10.87 (9.93, 11.90) among men. By April 2020 these relative differences had increased to more than 17 times with CMFs of 17.57 (16.43, 18.79) among women and 18.17 (17.22, 19.17) among men. CMFs did not increase during the second wave, despite a rise in the absolute age-standardised COVID-19 mortality risks. INTERPRETATION COVID-19 has had a disproportionate impact on the mortality of care home residents in England compared to older residents of private homes, but only in the first wave. This may be explained by a degree of acquired immunity, improved protective measures or changes in the underlying frailty of the populations. The care home population should be prioritised for measures aimed at controlling COVID-19. FUNDING Medical Research Council MR/V015737/1.
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Affiliation(s)
- Anna Schultze
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Emily Nightingale
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Alicia Rosello
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Chris Bates
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX
| | | | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Helen I McDonald
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | | | - Krishnan Bhaskaran
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Rohini Mathur
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Laurie A Tomlinson
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | | | - Harriet Forbes
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - John Tazare
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Daniel Grint
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Tom Ward
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Louis Fisher
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Amelia CA Green
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - Kevin Wing
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Angel YS Wong
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Robert McManus
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX
| | - John Parry
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX
| | - Frank Hester
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX
| | - Sam Harper
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX
| | - Stephen JW Evans
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Ian J Douglas
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Rosalind M Eggo
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX26GG
| | - David A Leon
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- International Laboratory For Population and Health, National Research University Higher School of Economics, Moscow, Russia
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19
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Fisher L, Speed V, Curtis HJ, Rentsch CT, Wong AYS, Schultze A, Massey J, Inglesby P, Morton CE, Wood M, Walker AJ, Morley J, Mehrkar A, Bacon S, Hickman G, Bates C, Croker R, Evans D, Ward T, Cockburn J, Davy S, Bhaskaran K, Smith B, Williamson E, Hulme W, Green A, Eggo RM, Forbes H, Tazare J, Parry J, Hester F, Harper S, Meadows J, O'Hanlon S, Eavis A, Jarvis R, Avramov D, Griffiths P, Fowles A, Parkes N, Douglas IJ, Evans SJW, Smeeth L, MacKenna B, Tomlinson L, Goldacre B. Potentially inappropriate prescribing of DOACs to people with mechanical heart valves: A federated analysis of 57.9 million patients' primary care records in situ using OpenSAFELY. Thromb Res 2022; 211:150-153. [PMID: 35168181 DOI: 10.1016/j.thromres.2022.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Louis Fisher
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Victoria Speed
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London SE5 9RS, United Kingdom of Great Britain and Northern Ireland
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Christopher T Rentsch
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Angel Y S Wong
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Anna Schultze
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Jon Massey
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Marion Wood
- NHS England and NHS Improvement, Skipton House, 80 London Road, London SE1 6LH, United Kingdom of Great Britain and Northern Ireland
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Jessica Morley
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Chris Bates
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, United Kingdom of Great Britain and Northern Ireland
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Tom Ward
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Jonathan Cockburn
- Faculty of Health Sciences, Bristol Medical School, Bristol BS8 1UD, United Kingdom of Great Britain and Northern Ireland
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Krishnan Bhaskaran
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Becky Smith
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Elizabeth Williamson
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Amelia Green
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland
| | - Rosalind M Eggo
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Harriet Forbes
- Faculty of Health Sciences, Bristol Medical School, Bristol BS8 1UD, United Kingdom of Great Britain and Northern Ireland
| | - John Tazare
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - John Parry
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, United Kingdom of Great Britain and Northern Ireland
| | - Frank Hester
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, United Kingdom of Great Britain and Northern Ireland
| | - Sam Harper
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, United Kingdom of Great Britain and Northern Ireland
| | - Jonathan Meadows
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Shaun O'Hanlon
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Alex Eavis
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Richard Jarvis
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Dima Avramov
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Paul Griffiths
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Aaron Fowles
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Nasreen Parkes
- EMIS Health, Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA, United Kingdom of Great Britain and Northern Ireland
| | - Ian J Douglas
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Stephen J W Evans
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland; NHS England and NHS Improvement, Skipton House, 80 London Road, London SE1 6LH, United Kingdom of Great Britain and Northern Ireland
| | - Laurie Tomlinson
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, United Kingdom of Great Britain and Northern Ireland.
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20
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Williamson EJ, Tazare J, Bhaskaran K, McDonald HI, Walker AJ, Tomlinson L, Wing K, Bacon S, Bates C, Curtis HJ, Forbes HJ, Minassian C, Morton CE, Nightingale E, Mehrkar A, Evans D, Nicholson BD, Leon DA, Inglesby P, MacKenna B, Davies NG, DeVito NJ, Drysdale H, Cockburn J, Hulme WJ, Morley J, Douglas I, Rentsch CT, Mathur R, Wong A, Schultze A, Croker R, Parry J, Hester F, Harper S, Grieve R, Harrison DA, Steyerberg EW, Eggo RM, Diaz-Ordaz K, Keogh R, Evans SJW, Smeeth L, Goldacre B. Comparison of methods for predicting COVID-19-related death in the general population using the OpenSAFELY platform. Diagn Progn Res 2022; 6:6. [PMID: 35197114 PMCID: PMC8865947 DOI: 10.1186/s41512-022-00120-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/04/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Obtaining accurate estimates of the risk of COVID-19-related death in the general population is challenging in the context of changing levels of circulating infection. METHODS We propose a modelling approach to predict 28-day COVID-19-related death which explicitly accounts for COVID-19 infection prevalence using a series of sub-studies from new landmark times incorporating time-updating proxy measures of COVID-19 infection prevalence. This was compared with an approach ignoring infection prevalence. The target population was adults registered at a general practice in England in March 2020. The outcome was 28-day COVID-19-related death. Predictors included demographic characteristics and comorbidities. Three proxies of local infection prevalence were used: model-based estimates, rate of COVID-19-related attendances in emergency care, and rate of suspected COVID-19 cases in primary care. We used data within the TPP SystmOne electronic health record system linked to Office for National Statistics mortality data, using the OpenSAFELY platform, working on behalf of NHS England. Prediction models were developed in case-cohort samples with a 100-day follow-up. Validation was undertaken in 28-day cohorts from the target population. We considered predictive performance (discrimination and calibration) in geographical and temporal subsets of data not used in developing the risk prediction models. Simple models were contrasted to models including a full range of predictors. RESULTS Prediction models were developed on 11,972,947 individuals, of whom 7999 experienced COVID-19-related death. All models discriminated well between individuals who did and did not experience the outcome, including simple models adjusting only for basic demographics and number of comorbidities: C-statistics 0.92-0.94. However, absolute risk estimates were substantially miscalibrated when infection prevalence was not explicitly modelled. CONCLUSIONS Our proposed models allow absolute risk estimation in the context of changing infection prevalence but predictive performance is sensitive to the proxy for infection prevalence. Simple models can provide excellent discrimination and may simplify implementation of risk prediction tools.
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Affiliation(s)
- Elizabeth J Williamson
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK.
| | - John Tazare
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Krishnan Bhaskaran
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Helen I McDonald
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
- NIHR Health Protection Research Unit (HPRU) in Immunisation, London, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Laurie Tomlinson
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Kevin Wing
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Chris Bates
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Harriet J Forbes
- University of Bristol, Beacon House, Queens Road, Bristol, BS8 1QU, UK
| | - Caroline Minassian
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Emily Nightingale
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Brian D Nicholson
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - David A Leon
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Nicholas G Davies
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | | | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Jessica Morley
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - Ian Douglas
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Christopher T Rentsch
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Rohini Mathur
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Angel Wong
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Anna Schultze
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| | - John Parry
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Frank Hester
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Sam Harper
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Richard Grieve
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), 24 High Holborn, Holborn, London, WC1V 6AZ, UK
| | | | - Rosalind M Eggo
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Karla Diaz-Ordaz
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Ruth Keogh
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Stephen J W Evans
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
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21
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Bhaskaran K, Rentsch CT, Hickman G, Hulme WJ, Schultze A, Curtis HJ, Wing K, Warren-Gash C, Tomlinson L, Bates CJ, Mathur R, MacKenna B, Mahalingasivam V, Wong A, Walker AJ, Morton CE, Grint D, Mehrkar A, Eggo RM, Inglesby P, Douglas IJ, McDonald HI, Cockburn J, Williamson EJ, Evans D, Parry J, Hester F, Harper S, Evans SJW, Bacon S, Smeeth L, Goldacre B. Overall and cause-specific hospitalisation and death after COVID-19 hospitalisation in England: A cohort study using linked primary care, secondary care, and death registration data in the OpenSAFELY platform. PLoS Med 2022; 19:e1003871. [PMID: 35077449 PMCID: PMC8789178 DOI: 10.1371/journal.pmed.1003871] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 06/11/2021] [Accepted: 11/17/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is concern about medium to long-term adverse outcomes following acute Coronavirus Disease 2019 (COVID-19), but little relevant evidence exists. We aimed to investigate whether risks of hospital admission and death, overall and by specific cause, are raised following discharge from a COVID-19 hospitalisation. METHODS AND FINDINGS With the approval of NHS-England, we conducted a cohort study, using linked primary care and hospital data in OpenSAFELY to compare risks of hospital admission and death, overall and by specific cause, between people discharged from COVID-19 hospitalisation (February to December 2020) and surviving at least 1 week, and (i) demographically matched controls from the 2019 general population; and (ii) people discharged from influenza hospitalisation in 2017 to 2019. We used Cox regression adjusted for age, sex, ethnicity, obesity, smoking status, deprivation, and comorbidities considered potential risk factors for severe COVID-19 outcomes. We included 24,673 postdischarge COVID-19 patients, 123,362 general population controls, and 16,058 influenza controls, followed for ≤315 days. COVID-19 patients had median age of 66 years, 13,733 (56%) were male, and 19,061 (77%) were of white ethnicity. Overall risk of hospitalisation or death (30,968 events) was higher in the COVID-19 group than general population controls (fully adjusted hazard ratio [aHR] 2.22, 2.14 to 2.30, p < 0.001) but slightly lower than the influenza group (aHR 0.95, 0.91 to 0.98, p = 0.004). All-cause mortality (7,439 events) was highest in the COVID-19 group (aHR 4.82, 4.48 to 5.19 versus general population controls [p < 0.001] and 1.74, 1.61 to 1.88 versus influenza controls [p < 0.001]). Risks for cause-specific outcomes were higher in COVID-19 survivors than in general population controls and largely similar or lower in COVID-19 compared with influenza patients. However, COVID-19 patients were more likely than influenza patients to be readmitted or die due to their initial infection or other lower respiratory tract infection (aHR 1.37, 1.22 to 1.54, p < 0.001) and to experience mental health or cognitive-related admission or death (aHR 1.37, 1.02 to 1.84, p = 0.039); in particular, COVID-19 survivors with preexisting dementia had higher risk of dementia hospitalisation or death (age- and sex-adjusted HR 2.47, 1.37 to 4.44, p = 0.002). Limitations of our study were that reasons for hospitalisation or death may have been misclassified in some cases due to inconsistent use of codes, and we did not have data to distinguish COVID-19 variants. CONCLUSIONS In this study, we observed that people discharged from a COVID-19 hospital admission had markedly higher risks for rehospitalisation and death than the general population, suggesting a substantial extra burden on healthcare. Most risks were similar to those observed after influenza hospitalisations, but COVID-19 patients had higher risks of all-cause mortality, readmission or death due to the initial infection, and dementia death, highlighting the importance of postdischarge monitoring.
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Affiliation(s)
- Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christopher T. Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - William J. Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen J. Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Kevin Wing
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charlotte Warren-Gash
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Viyaasan Mahalingasivam
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angel Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alex J. Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Caroline E. Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Daniel Grint
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rosalind M. Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ian J. Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen I. McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Elizabeth J. Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - John Parry
- TPP, TPP House, Horsforth, Leeds, United Kingdom
| | - Frank Hester
- TPP, TPP House, Horsforth, Leeds, United Kingdom
| | - Sam Harper
- TPP, TPP House, Horsforth, Leeds, United Kingdom
| | - Stephen JW Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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22
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Rowan A, Bates C, Hulme W, Evans D, Davy S, A Kennedy N, Galloway J, E Mansfield K, Bechman K, Matthewman J, Yates M, Brown J, Schultze A, Norton S, J. Walker A, E. Morton C, Bhaskaran K, T. Rentsch C, Williamson E, Croker R, Bacon S, Hickman G, Ward T, Green A, Fisher L, J Curtis H, Tazare J, M. Eggo R, Inglesby P, Cockburn J, I. McDonald H, Mathur R, YS Wong A, Forbes H, Parry J, Hester F, Harper S, J Douglas I, Smeeth L, A Tomlinson L, W Lees C, Evans S, Smith C, M. Langan S, Mehkar A, MacKenna B, Goldacre B. A comprehensive high cost drugs dataset from the NHS in England - An OpenSAFELY-TPP Short Data Report. Wellcome Open Res 2021; 6:360. [PMID: 35634533 PMCID: PMC9120928 DOI: 10.12688/wellcomeopenres.17360.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/20/2022] Open
Abstract
Background: At the outset of the COVID-19 pandemic, there was no routine comprehensive hospital medicines data from the UK available to researchers. These records can be important for many analyses including the effect of certain medicines on the risk of severe COVID-19 outcomes. With the approval of NHS England, we set out to obtain data on one specific group of medicines, "high-cost drugs" (HCD) which are typically specialist medicines for the management of long-term conditions, prescribed by hospitals to patients. Additionally, we aimed to make these data available to all approved researchers in OpenSAFELY-TPP. This report is intended to support all studies carried out in OpenSAFELY-TPP, and those elsewhere, working with this dataset or similar data. Methods: Working with the North East Commissioning Support Unit and NHS Digital, we arranged for collation of a single national HCD dataset to help inform responses to the COVID-19 pandemic. The dataset was developed from payment submissions from hospitals to commissioners. Results: In the financial year (FY) 2018/19 there were 2.8 million submissions for 1.1 million unique patient IDs recorded in the HCD. The average number of submissions per patient over the year was 2.6. In FY 2019/20 there were 4.0 million submissions for 1.3 million unique patient IDs. The average number of submissions per patient over the year was 3.1. Of the 21 variables in the dataset, three are now available for analysis in OpenSafely-TPP: Financial year and month of drug being dispensed; drug name; and a description of the drug dispensed. Conclusions: We have described the process for sourcing a national HCD dataset, making these data available for COVID-19-related analysis through OpenSAFELY-TPP and provided information on the variables included in the dataset, data coverage and an initial descriptive analysis.
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Affiliation(s)
- Anna Rowan
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Chris Bates
- TPP, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- IBD Research Group, University of Exeter, Exeter, UK
| | - James Galloway
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Kathryn E Mansfield
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Katie Bechman
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Julian Matthewman
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Mark Yates
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Jeremy Brown
- Centre of Rheumatic Diseases, King's College London, London, UK
| | - Anna Schultze
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Sam Norton
- TPP, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Alex J. Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Caroline E. Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Krishnan Bhaskaran
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Christopher T. Rentsch
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Elizabeth Williamson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Tom Ward
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Amelia Green
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Louis Fisher
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - John Tazare
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Rosalind M. Eggo
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | | | - Helen I. McDonald
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Rohini Mathur
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Angel YS Wong
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Harriet Forbes
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - John Parry
- TPP, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Frank Hester
- TPP, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Sam Harper
- TPP, 129 Low Lane, Horsforth, Leeds, LS18 5PX, UK
| | - Ian J Douglas
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Liam Smeeth
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Laurie A Tomlinson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Charlie W Lees
- Centre for Genomics and Experimental Medicine, University of Edinburgh, Edinburgh, UK
| | - Stephen Evans
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Catherine Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, UK
| | - Sinéad M. Langan
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, UK
| | - Amir Mehkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Curtis HJ, MacKenna B, Walker AJ, Croker R, Mehrkar A, Morton C, Bacon S, Hickman G, Inglesby P, Bates C, Evans D, Ward T, Cockburn J, Davy S, Bhaskaran K, Schultze A, Rentsch CT, Williamson E, Hulme W, Tomlinson L, Mathur R, Drysdale H, Eggo RM, Wong AY, Forbes H, Parry J, Hester F, Harper S, Douglas I, Smeeth L, Goldacre B. OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic. Open Heart 2021; 8:e001784. [PMID: 34785588 PMCID: PMC8595296 DOI: 10.1136/openhrt-2021-001784] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Early in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring. OBJECTIVE To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic. METHODS With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England. RESULTS 20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420). CONCLUSIONS Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.
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Affiliation(s)
- Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom Ward
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Krishnan Bhaskaran
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Schultze
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher T Rentsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Laurie Tomlinson
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rohini Mathur
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rosalind M Eggo
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Angel Yun Wong
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet Forbes
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | - Ian Douglas
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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24
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Walker AJ, MacKenna B, Inglesby P, Tomlinson L, Rentsch CT, Curtis HJ, Morton CE, Morley J, Mehrkar A, Bacon S, Hickman G, Bates C, Croker R, Evans D, Ward T, Cockburn J, Davy S, Bhaskaran K, Schultze A, Williamson EJ, Hulme WJ, McDonald HI, Mathur R, Eggo RM, Wing K, Wong AY, Forbes H, Tazare J, Parry J, Hester F, Harper S, O'Hanlon S, Eavis A, Jarvis R, Avramov D, Griffiths P, Fowles A, Parkes N, Douglas IJ, Evans SJ. Clinical coding of long COVID in English primary care: a federated analysis of 58 million patient records in situ using OpenSAFELY. Br J Gen Pract 2021; 71:e806-e814. [PMID: 34340970 PMCID: PMC8340730 DOI: 10.3399/bjgp.2021.0301] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [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: 05/07/2021] [Accepted: 06/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Long COVID describes new or persistent symptoms at least 4 weeks after onset of acute COVID-19. Clinical codes to describe this phenomenon were recently created. AIM To describe the use of long-COVID codes, and variation of use by general practice, demographic variables, and over time. DESIGN AND SETTING Population-based cohort study in English primary care. METHOD Working on behalf of NHS England, OpenSAFELY data were used encompassing 96% of the English population between 1 February 2020 and 25 May 2021. The proportion of people with a recorded code for long COVID was measured overall and by demographic factors, electronic health record software system (EMIS or TPP), and week. RESULTS Long COVID was recorded for 23 273 people. Coding was unevenly distributed among practices, with 26.7% of practices having never used the codes. Regional variation ranged between 20.3 per 100 000 people for East of England (95% confidence interval [CI] = 19.3 to 21.4) and 55.6 per 100 000 people in London (95% CI = 54.1 to 57.1). Coding was higher among females (52.1, 95% CI = 51.3 to 52.9) than males (28.1, 95% CI = 27.5 to 28.7), and higher among practices using EMIS (53.7, 95% CI = 52.9 to 54.4) than those using TPP (20.9, 95% CI = 20.3 to 21.4). CONCLUSION Current recording of long COVID in primary care is very low, and variable between practices. This may reflect patients not presenting; clinicians and patients holding different diagnostic thresholds; or challenges with the design and communication of diagnostic codes. Increased awareness of diagnostic codes is recommended to facilitate research and planning of services, and also surveys with qualitative work to better evaluate clinicians' understanding of the diagnosis.
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Affiliation(s)
- Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Jessica Morley
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | | | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Tom Ward
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | | | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Elizabeth J Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Rosalind M Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Kevin Wing
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Angel Ys Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Harriet Forbes
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - John Tazare
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | | | | | | | | | | | | | | | | | | | | | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Stephen Jw Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
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25
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Wong AYS, Tomlinson LA, Brown JP, Elson W, Walker AJ, Schultze A, Morton CE, Evans D, Inglesby P, MacKenna B, Bhaskaran K, Rentsch CT, Powell E, Williamson E, Croker R, Bacon S, Hulme W, Bates C, Curtis HJ, Mehrkar A, Cockburn J, McDonald HI, Mathur R, Wing K, Forbes H, Eggo RM, Evans SJW, Smeeth L, Goldacre B, Douglas IJ. Association between warfarin and COVID-19-related outcomes compared with direct oral anticoagulants: population-based cohort study. J Hematol Oncol 2021; 14:172. [PMID: 34666811 PMCID: PMC8525065 DOI: 10.1186/s13045-021-01185-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Thromboembolism has been reported as a consequence of severe COVID-19. Although warfarin is a commonly used anticoagulant, it acts by antagonising vitamin K, which is low in patients with severe COVID-19. To date, the clinical evidence on the impact of regular use of warfarin on COVID-19-related thromboembolism is lacking. METHODS On behalf of NHS England, we conducted a population-based cohort study investigating the association between warfarin and COVID-19 outcomes compared with direct oral anticoagulants (DOACs). We used the OpenSAFELY platform to analyse primary care data and pseudonymously linked SARS-CoV-2 antigen testing data, hospital admissions and death records from England. We used Cox regression to estimate hazard ratios (HRs) for COVID-19-related outcomes comparing warfarin with DOACs in people with non-valvular atrial fibrillation. We also conducted negative control outcome analyses (being tested for SARS-CoV-2 and non-COVID-19 death) to assess the potential impact of confounding. RESULTS A total of 92,339 warfarin users and 280,407 DOAC users were included. We observed a lower risk of all outcomes associated with warfarin versus DOACs [testing positive for SARS-CoV-2, HR 0.73 (95% CI 0.68-0.79); COVID-19-related hospital admission, HR 0.75 (95% CI 0.68-0.83); COVID-19-related deaths, HR 0.74 (95% CI 0.66-0.83)]. A lower risk of negative control outcomes associated with warfarin versus DOACs was also observed [being tested for SARS-CoV-2, HR 0.80 (95% CI 0.79-0.81); non-COVID-19 deaths, HR 0.79 (95% CI 0.76-0.83)]. CONCLUSIONS Overall, this study shows no evidence of harmful effects of warfarin on severe COVID-19 disease.
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Affiliation(s)
| | - Angel Y S Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Laurie A Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy P Brown
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - William Elson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Emma Powell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,NIHR Health Protection Research Unit (HPRU) in Immunisation, London, UK
| | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kevin Wing
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Harriet Forbes
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Rosalind M Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen J W Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,NIHR Health Protection Research Unit (HPRU) in Immunisation, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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26
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Williamson EJ, McDonald HI, Bhaskaran K, Walker AJ, Bacon S, Davy S, Schultze A, Tomlinson L, Bates C, Ramsay M, Curtis HJ, Forbes H, Wing K, Minassian C, Tazare J, Morton CE, Nightingale E, Mehrkar A, Evans D, Inglesby P, MacKenna B, Cockburn J, Rentsch CT, Mathur R, Wong AYS, Eggo RM, Hulme W, Croker R, Parry J, Hester F, Harper S, Douglas IJ, Evans SJW, Smeeth L, Goldacre B, Kuper H. Risks of covid-19 hospital admission and death for people with learning disability: population based cohort study using the OpenSAFELY platform. BMJ 2021; 374:n1592. [PMID: 34261639 PMCID: PMC8278652 DOI: 10.1136/bmj.n1592] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [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] [Accepted: 06/09/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the association between learning disability and risk of hospital admission and death from covid-19 in England among adults and children. DESIGN Population based cohort study on behalf of NHS England using the OpenSAFELY platform. SETTING Patient level data were obtained for more than 17 million people registered with a general practice in England that uses TPP software. Electronic health records were linked with death data from the Office for National Statistics and hospital admission data from NHS Secondary Uses Service. PARTICIPANTS Adults (aged 16-105 years) and children (<16 years) from two cohorts: wave 1 (registered with a TPP practice as of 1 March 2020 and followed until 31 August 2020); and wave 2 (registered 1 September 2020 and followed until 8 February 2021). The main exposure group consisted of people on a general practice learning disability register; a subgroup was defined as those having profound or severe learning disability. People with Down's syndrome and cerebral palsy were identified (whether or not they were on the learning disability register). MAIN OUTCOME MEASURE Covid-19 related hospital admission and covid-19 related death. Non-covid-19 deaths were also explored. RESULTS For wave 1, 14 312 023 adults aged ≥16 years were included, and 90 307 (0.63%) were on the learning disability register. Among adults on the register, 538 (0.6%) had a covid-19 related hospital admission; there were 222 (0.25%) covid-19 related deaths and 602 (0.7%) non-covid deaths. Among adults not on the register, 29 781 (0.2%) had a covid-19 related hospital admission; there were 13 737 (0.1%) covid-19 related deaths and 69 837 (0.5%) non-covid deaths. Wave 1 hazard ratios for adults on the learning disability register (adjusted for age, sex, ethnicity, and geographical location) were 5.3 (95% confidence interval 4.9 to 5.8) for covid-19 related hospital admission and 8.2 (7.2 to 9.4) for covid-19 related death. Wave 2 produced similar estimates. Associations were stronger among those classified as having severe to profound learning disability, and among those in residential care. For both waves, Down's syndrome and cerebral palsy were associated with increased hazards for both events; Down's syndrome to a greater extent. Hazard ratios for non-covid deaths followed similar patterns with weaker associations. Similar patterns of increased relative risk were seen for children, but covid-19 related deaths and hospital admissions were rare, reflecting low event rates among children. CONCLUSIONS People with learning disability have markedly increased risks of hospital admission and death from covid-19, over and above the risks observed for non-covid causes of death. Prompt access to covid-19 testing and healthcare is warranted for this vulnerable group, and prioritisation for covid-19 vaccination and other targeted preventive measures should be considered.
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Affiliation(s)
| | - Helen I McDonald
- London School of Hygiene and Tropical Medicine, London, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit in Vaccines and Immunisation, London, UK
| | | | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Schultze
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Mary Ramsay
- National Institute for Health Research (NIHR) Health Protection Research Unit in Vaccines and Immunisation, London, UK
- Public Health England, London, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Kevin Wing
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - John Tazare
- London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dave Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Rohini Mathur
- London School of Hygiene and Tropical Medicine, London, UK
| | - Angel Y S Wong
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | - Ian J Douglas
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ben Goldacre
- National Institute for Health Research (NIHR) Health Protection Research Unit in Vaccines and Immunisation, London, UK
| | - Hannah Kuper
- London School of Hygiene and Tropical Medicine, London, UK
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27
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Bhaskaran K, Bacon S, Evans SJW, Bates CJ, Rentsch CT, MacKenna B, Tomlinson L, Walker AJ, Schultze A, Morton CE, Grint D, Mehrkar A, Eggo RM, Inglesby P, Douglas IJ, McDonald HI, Cockburn J, Williamson EJ, Evans D, Curtis HJ, Hulme WJ, Parry J, Hester F, Harper S, Spiegelhalter D, Smeeth L, Goldacre B. Factors associated with deaths due to COVID-19 versus other causes: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. Lancet Reg Health Eur 2021; 6:100109. [PMID: 33997835 PMCID: PMC8106239 DOI: 10.1016/j.lanepe.2021.100109] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Mortality from COVID-19 shows a strong relationship with age and pre-existing medical conditions, as does mortality from other causes. We aimed to investigate how specific factors are differentially associated with COVID-19 mortality as compared to mortality from causes other than COVID-19. METHODS Working on behalf of NHS England, we carried out a cohort study within the OpenSAFELY platform. Primary care data from England were linked to national death registrations. We included all adults (aged ≥18 years) in the database on 1st February 2020 and with >1 year of continuous prior registration; the cut-off date for deaths was 9th November 2020. Associations between individual-level characteristics and COVID-19 and non-COVID deaths, classified according to the presence of a COVID-19 code as the underlying cause of death on the death certificate, were estimated by fitting age- and sex-adjusted logistic models for these two outcomes. FINDINGS 17,456,515 individuals were included. 17,063 died from COVID-19 and 134,316 from other causes. Most factors associated with COVID-19 death were similarly associated with non-COVID death, but the magnitudes of association differed. Older age was more strongly associated with COVID-19 death than non-COVID death (e.g. ORs 40.7 [95% CI 37.7-43.8] and 29.6 [28.9-30.3] respectively for ≥80 vs 50-59 years), as was male sex, deprivation, obesity, and some comorbidities. Smoking, history of cancer and chronic liver disease had stronger associations with non-COVID than COVID-19 death. All non-white ethnic groups had higher odds than white of COVID-19 death (OR for Black: 2.20 [1.96-2.47], South Asian: 2.33 [2.16-2.52]), but lower odds than white of non-COVID death (Black: 0.88 [0.83-0.94], South Asian: 0.78 [0.75-0.81]). INTERPRETATION Similar associations of most individual-level factors with COVID-19 and non-COVID death suggest that COVID-19 largely multiplies existing risks faced by patients, with some notable exceptions. Identifying the unique factors contributing to the excess COVID-19 mortality risk among non-white groups is a priority to inform efforts to reduce deaths from COVID-19. FUNDING Wellcome, Royal Society, National Institute for Health Research, National Institute for Health Research Oxford Biomedical Research Centre, UK Medical Research Council, Health Data Research UK.
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Affiliation(s)
- Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stephen JW Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Chris J Bates
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Daniel Grint
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rosalind M Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | | | - Elizabeth J Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John Parry
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - Frank Hester
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - Sam Harper
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - David Spiegelhalter
- Winton Centre for Risk and Evidence Communication, Statistical Laboratory Centre for Mathematical Sciences, Cambridge, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Wong AY, MacKenna B, Morton CE, Schultze A, Walker AJ, Bhaskaran K, Brown JP, Rentsch CT, Williamson E, Drysdale H, Croker R, Bacon S, Hulme W, Bates C, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, Tomlinson L, Mathur R, Wing K, Forbes H, Eggo RM, Parry J, Hester F, Harper S, Evans SJ, Smeeth L, Douglas IJ, Goldacre B. Use of non-steroidal anti-inflammatory drugs and risk of death from COVID-19: an OpenSAFELY cohort analysis based on two cohorts. Ann Rheum Dis 2021; 80:943-951. [PMID: 33478953 PMCID: PMC7823433 DOI: 10.1136/annrheumdis-2020-219517] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [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: 11/16/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To assess the association between routinely prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and deaths from COVID-19 using OpenSAFELY, a secure analytical platform. METHODS We conducted two cohort studies from 1 March to 14 June 2020. Working on behalf of National Health Service England, we used routine clinical data in England linked to death data. In study 1, we identified people with an NSAID prescription in the last 3 years from the general population. In study 2, we identified people with rheumatoid arthritis/osteoarthritis. We defined exposure as current NSAID prescription within the 4 months before 1 March 2020. We used Cox regression to estimate HRs for COVID-19 related death in people currently prescribed NSAIDs, compared with those not currently prescribed NSAIDs, accounting for age, sex, comorbidities, other medications and geographical region. RESULTS In study 1, we included 536 423 current NSAID users and 1 927 284 non-users in the general population. We observed no evidence of difference in risk of COVID-19 related death associated with current use (HR 0.96, 95% CI 0.80 to 1.14) in the multivariable-adjusted model. In study 2, we included 1 708 781 people with rheumatoid arthritis/osteoarthritis, of whom 175 495 (10%) were current NSAID users. In the multivariable-adjusted model, we observed a lower risk of COVID-19 related death (HR 0.78, 95% CI 0.64 to 0.94) associated with current use of NSAID versus non-use. CONCLUSIONS We found no evidence of a harmful effect of routinely prescribed NSAIDs on COVID-19 related deaths. Risks of COVID-19 do not need to influence decisions about the routine therapeutic use of NSAIDs.
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Affiliation(s)
- Angel Ys Wong
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Anna Schultze
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeremy P Brown
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher T Rentsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Helen I McDonald
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Laurie Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Wing
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet Forbes
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rosalind M Eggo
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Stephen Jw Evans
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
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Ghanima W, Schultze A, Donaldson R, Brodin E, Halvorsen S, Graham S, Carroll R, Ulvestad M, Lambrelli D. Oral Anticoagulation Therapy for Venous Thromboembolism in Norway: Time Trends and Treatment Patterns. Clin Ther 2021; 43:1179-1190.e3. [PMID: 34083030 DOI: 10.1016/j.clinthera.2021.04.017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 04/20/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Data describing treatment patterns of patients with venous thromboembolism (VTE) patients in Scandinavia are scarce. This study sought to address this scarcity by describing demographic and clinical characteristics, trends in the use of oral anticoagulants (OACs), and treatment patterns in patients treated for VTE in Norway between 2013 and 2017. METHODS Using data from Norway's nationwide registries, a cohort study included patients newly (after 2008) treated OACs who were diagnosed with VTE between January 2013 and December 2017 and were dispensed an OAC (warfarin, apixaban, rivaroxaban, dabigatran, or edoxaban) within 30 days. Patient characteristics and the percentage of patients with VTE who initiated treatment with each OAC for each calendar year were reported. Initial therapy persistence was assessed using Kaplan-Meier curves and compared between the OAC groups using the log-rank test. FINDINGS The comorbidity burden was similar between patients taking warfarin and those taking apixaban but lower among patients taking rivaroxaban. Direct oral anticoagulant (DOAC) use increased from 33.2% to 93.6% during the study period, whereas warfarin use decreased. Persistence was higher in the apixaban cohort compared with the warfarin cohort, with the difference mostly apparent after 6 months, whereas persistence was similar between the patients taking rivaroxaban and those taking warfarin. IMPLICATIONS Between 2013 and 2017, DOAC use among patients with VTEs increased markedly in Norway, whereas the use of warfarin decreased. Patients taking apixaban had higher persistence compared with those taking warfarin, whereas patients taking warfarin and those taking rivaroxaban had similar persistence. Further studies with longer follow-up are required to examine the use of extended OAC treatment for VTE.
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Affiliation(s)
- Waleed Ghanima
- Department of Medicine, Østfold Hospital, Grålum, Norway; Department of Hematology, Østfold Hospital, Grålum, Norway; Department of Research, Østfold Hospital, Grålum, Norway; Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | | | - Robert Donaldson
- Hematological Research Group, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Ellen Brodin
- Hematological Research Group, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Sigrun Halvorsen
- Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Oslo, Norway
| | - Sophie Graham
- Hematological Research Group, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
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Mathur R, Rentsch CT, Morton CE, Hulme WJ, Schultze A, MacKenna B, Eggo RM, Bhaskaran K, Wong AYS, Williamson EJ, Forbes H, Wing K, McDonald HI, Bates C, Bacon S, Walker AJ, Evans D, Inglesby P, Mehrkar A, Curtis HJ, DeVito NJ, Croker R, Drysdale H, Cockburn J, Parry J, Hester F, Harper S, Douglas IJ, Tomlinson L, Evans SJW, Grieve R, Harrison D, Rowan K, Khunti K, Chaturvedi N, Smeeth L, Goldacre B. Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform. Lancet 2021; 397:1711-1724. [PMID: 33939953 PMCID: PMC8087292 DOI: 10.1016/s0140-6736(21)00634-6] [Citation(s) in RCA: 236] [Impact Index Per Article: 78.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/26/2021] [Accepted: 03/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND COVID-19 has disproportionately affected minority ethnic populations in the UK. Our aim was to quantify ethnic differences in SARS-CoV-2 infection and COVID-19 outcomes during the first and second waves of the COVID-19 pandemic in England. METHODS We conducted an observational cohort study of adults (aged ≥18 years) registered with primary care practices in England for whom electronic health records were available through the OpenSAFELY platform, and who had at least 1 year of continuous registration at the start of each study period (Feb 1 to Aug 3, 2020 [wave 1], and Sept 1 to Dec 31, 2020 [wave 2]). Individual-level primary care data were linked to data from other sources on the outcomes of interest: SARS-CoV-2 testing and positive test results and COVID-19-related hospital admissions, intensive care unit (ICU) admissions, and death. The exposure was self-reported ethnicity as captured on the primary care record, grouped into five high-level census categories (White, South Asian, Black, other, and mixed) and 16 subcategories across these five categories, as well as an unknown ethnicity category. We used multivariable Cox regression to examine ethnic differences in the outcomes of interest. Models were adjusted for age, sex, deprivation, clinical factors and comorbidities, and household size, with stratification by geographical region. FINDINGS Of 17 288 532 adults included in the study (excluding care home residents), 10 877 978 (62·9%) were White, 1 025 319 (5·9%) were South Asian, 340 912 (2·0%) were Black, 170 484 (1·0%) were of mixed ethnicity, 320 788 (1·9%) were of other ethnicity, and 4 553 051 (26·3%) were of unknown ethnicity. In wave 1, the likelihood of being tested for SARS-CoV-2 infection was slightly higher in the South Asian group (adjusted hazard ratio 1·08 [95% CI 1·07-1·09]), Black group (1·08 [1·06-1·09]), and mixed ethnicity group (1·04 [1·02-1·05]) and was decreased in the other ethnicity group (0·77 [0·76-0·78]) relative to the White group. The risk of testing positive for SARS-CoV-2 infection was higher in the South Asian group (1·99 [1·94-2·04]), Black group (1·69 [1·62-1·77]), mixed ethnicity group (1·49 [1·39-1·59]), and other ethnicity group (1·20 [1·14-1·28]). Compared with the White group, the four remaining high-level ethnic groups had an increased risk of COVID-19-related hospitalisation (South Asian group 1·48 [1·41-1·55], Black group 1·78 [1·67-1·90], mixed ethnicity group 1·63 [1·45-1·83], other ethnicity group 1·54 [1·41-1·69]), COVID-19-related ICU admission (2·18 [1·92-2·48], 3·12 [2·65-3·67], 2·96 [2·26-3·87], 3·18 [2·58-3·93]), and death (1·26 [1·15-1·37], 1·51 [1·31-1·71], 1·41 [1·11-1·81], 1·22 [1·00-1·48]). In wave 2, the risks of hospitalisation, ICU admission, and death relative to the White group were increased in the South Asian group but attenuated for the Black group compared with these risks in wave 1. Disaggregation into 16 ethnicity groups showed important heterogeneity within the five broader categories. INTERPRETATION Some minority ethnic populations in England have excess risks of testing positive for SARS-CoV-2 and of adverse COVID-19 outcomes compared with the White population, even after accounting for differences in sociodemographic, clinical, and household characteristics. Causes are likely to be multifactorial, and delineating the exact mechanisms is crucial. Tackling ethnic inequalities will require action across many fronts, including reducing structural inequalities, addressing barriers to equitable care, and improving uptake of testing and vaccination. FUNDING Medical Research Council.
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Affiliation(s)
- Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Christopher T Rentsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Schultze
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rosalind M Eggo
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Angel Y S Wong
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth J Williamson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet Forbes
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Wing
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Helen I McDonald
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; National Institute for Health Research Health Protection Research Unit in Immunisation, London, UK
| | | | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Laurie Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen J W Evans
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - Kathy Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Nishi Chaturvedi
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Schultze A, Bates C, Cockburn J, MacKenna B, Nightingale E, Curtis HJ, Hulme WJ, Morton CE, Croker R, Bacon S, McDonald HI, Rentsch CT, Bhaskaran K, Mathur R, Tomlinson LA, Williamson EJ, Forbes H, Tazare J, Grint DJ, Walker AJ, Inglesby P, DeVito NJ, Mehrkar A, Hickman G, Davy S, Ward T, Fisher L, Evans D, Wing K, Wong AYS, McManus R, Parry J, Hester F, Harper S, Evans SJW, Douglas IJ, Smeeth L, Eggo RM, Goldacre B. Identifying Care Home Residents in Electronic Health Records - An OpenSAFELY Short Data Report. Wellcome Open Res 2021; 6:90. [PMID: 34471703 PMCID: PMC8374378 DOI: 10.12688/wellcomeopenres.16737.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Care home residents have been severely affected by the COVID-19 pandemic. Electronic Health Records (EHR) hold significant potential for studying the healthcare needs of this vulnerable population; however, identifying care home residents in EHR is not straightforward. We describe and compare three different methods for identifying care home residents in the newly created OpenSAFELY-TPP data analytics platform. Methods: Working on behalf of NHS England, we identified individuals aged 65 years or older potentially living in a care home on the 1st of February 2020 using (1) a complex address linkage, in which cleaned GP registered addresses were matched to old age care home addresses using data from the Care and Quality Commission (CQC); (2) coded events in the EHR; (3) household identifiers, age and household size to identify households with more than 3 individuals aged 65 years or older as potential care home residents. Raw addresses were not available to the investigators. Results: Of 4,437,286 individuals aged 65 years or older, 2.27% were identified as potential care home residents using the complex address linkage, 1.96% using coded events, 3.13% using household size and age and 3.74% using either of these methods. 53,210 individuals (32.0% of all potential care home residents) were classified as care home residents using all three methods. Address linkage had the largest overlap with the other methods; 93.3% of individuals identified as care home residents using the address linkage were also identified as such using either coded events or household age and size. Conclusion: We have described the partial overlap between three methods for identifying care home residents in EHR, and provide detailed instructions for how to implement these in OpenSAFELY-TPP to support research into the impact of the COVID-19 pandemic on care home residents.
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Affiliation(s)
- Anna Schultze
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Chris Bates
- The Phoenix Partnership, Leeds, LS18 5PX, UK
| | | | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Emily Nightingale
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, Select, WC1E 7HT, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Helen I McDonald
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Christopher T Rentsch
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Krishnan Bhaskaran
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Rohini Mathur
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Laurie A Tomlinson
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Elizabeth J Williamson
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Harriet Forbes
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - John Tazare
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Daniel J Grint
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Tom Ward
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Louis Fisher
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Kevin Wing
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Angel YS Wong
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | | | - John Parry
- The Phoenix Partnership, Leeds, LS18 5PX, UK
| | | | - Sam Harper
- The Phoenix Partnership, Leeds, LS18 5PX, UK
| | - Stephen JW Evans
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ian J Douglas
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Liam Smeeth
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Rosalind M Eggo
- 1 Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, Select, WC1E 7HT, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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32
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Forbes H, Morton CE, Bacon S, McDonald HI, Minassian C, Brown JP, Rentsch CT, Mathur R, Schultze A, DeVito NJ, MacKenna B, Hulme WJ, Croker R, Walker AJ, Williamson EJ, Bates C, Mehrkar A, Curtis HJ, Evans D, Wing K, Inglesby P, Drysdale H, Wong AYS, Cockburn J, McManus R, Parry J, Hester F, Harper S, Douglas IJ, Smeeth L, Evans SJW, Bhaskaran K, Eggo RM, Goldacre B, Tomlinson LA. Association between living with children and outcomes from covid-19: OpenSAFELY cohort study of 12 million adults in England. BMJ 2021; 372:n628. [PMID: 33737413 PMCID: PMC7970340 DOI: 10.1136/bmj.n628] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [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] [Accepted: 03/07/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate whether risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and outcomes of coronavirus disease 2019 (covid-19) differed between adults living with and without children during the first two waves of the UK pandemic. DESIGN Population based cohort study, on behalf of NHS England. SETTING Primary care data and pseudonymously linked hospital and intensive care admissions and death records from England, during wave 1 (1 February to 31 August 2020) and wave 2 (1 September to 18 December 2020). PARTICIPANTS Two cohorts of adults (18 years and over) registered at a general practice on 1 February 2020 and 1 September 2020. MAIN OUTCOME MEASURES Adjusted hazard ratios for SARS-CoV-2 infection, covid-19 related admission to hospital or intensive care, or death from covid-19, by presence of children in the household. RESULTS Among 9 334 392adults aged 65 years and under, during wave 1, living with children was not associated with materially increased risks of recorded SARS-CoV-2 infection, covid-19 related hospital or intensive care admission, or death from covid-19. In wave 2, among adults aged 65 years and under, living with children of any age was associated with an increased risk of recorded SARS-CoV-2 infection (hazard ratio 1.06 (95% confidence interval 1.05 to 1.08) for living with children aged 0-11 years; 1.22 (1.20 to 1.24) for living with children aged 12-18 years) and covid-19 related hospital admission (1.18 (1.06 to 1.31) for living with children aged 0-11; 1.26 (1.12 to 1.40) for living with children aged 12-18). Living with children aged 0-11 was associated with reduced risk of death from both covid-19 and non-covid-19 causes in both waves; living with children of any age was also associated with lower risk of dying from non-covid-19 causes. For adults 65 years and under during wave 2, living with children aged 0-11 years was associated with an increased absolute risk of having SARS-CoV-2 infection recorded of 40-60 per 10 000 people, from 810 to between 850 and 870, and an increase in the number of hospital admissions of 1-5 per 10 000 people, from 160 to between 161 and 165. Living with children aged 12-18 years was associated with an increase of 160-190 per 10 000 in the number of SARS-CoV-2 infections and an increase of 2-6 per 10 000 in the number of hospital admissions. CONCLUSIONS In contrast to wave 1, evidence existed of increased risk of reported SARS-CoV-2 infection and covid-19 outcomes among adults living with children during wave 2. However, this did not translate into a materially increased risk of covid-19 mortality, and absolute increases in risk were small.
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Affiliation(s)
- Harriet Forbes
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Helen I McDonald
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline Minassian
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy P Brown
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher T Rentsch
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Rohini Mathur
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Schultze
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Elizabeth J Williamson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Bates
- The Phoenix Partnership, 129 Low Lane, Horsforth, Leeds, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Kevin Wing
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Angel Y S Wong
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Robert McManus
- The Phoenix Partnership, 129 Low Lane, Horsforth, Leeds, UK
| | - John Parry
- The Phoenix Partnership, 129 Low Lane, Horsforth, Leeds, UK
| | - Frank Hester
- The Phoenix Partnership, 129 Low Lane, Horsforth, Leeds, UK
| | - Sam Harper
- The Phoenix Partnership, 129 Low Lane, Horsforth, Leeds, UK
| | - Ian J Douglas
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen J W Evans
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Rosalind M Eggo
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Laurie A Tomlinson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Rentsch CT, DeVito NJ, MacKenna B, Morton CE, Bhaskaran K, Brown JP, Schultze A, Hulme WJ, Croker R, Walker AJ, Williamson EJ, Bates C, Bacon S, Mehrkar A, Curtis HJ, Evans D, Wing K, Inglesby P, Mathur R, Drysdale H, Wong AYS, McDonald HI, Cockburn J, Forbes H, Parry J, Hester F, Harper S, Smeeth L, Douglas IJ, Dixon WG, Evans SJW, Tomlinson L, Goldacre B. Hydroxychloroquine treatment does not reduce COVID-19 mortality; underdosing to the wrong patients? - Authors' reply. Lancet Rheumatol 2021; 3:e172-e173. [PMID: 33655224 PMCID: PMC7906669 DOI: 10.1016/s2665-9913(21)00030-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christopher T Rentsch
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Krishnan Bhaskaran
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Jeremy P Brown
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Anna Schultze
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth J Williamson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Chris Bates
- The Phoenix Partnership, Horsforth, Leeds, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kevin Wing
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rohini Mathur
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Angel Y S Wong
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Helen I McDonald
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | | | - Harriet Forbes
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - John Parry
- The Phoenix Partnership, Horsforth, Leeds, UK
| | | | - Sam Harper
- The Phoenix Partnership, Horsforth, Leeds, UK
| | - Liam Smeeth
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Ian J Douglas
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - William G Dixon
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK
| | - Stephen J W Evans
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Laurie Tomlinson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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34
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Grint DJ, Wing K, Williamson E, McDonald HI, Bhaskaran K, Evans D, Evans SJ, Walker AJ, Hickman G, Nightingale E, Schultze A, Rentsch CT, Bates C, Cockburn J, Curtis HJ, Morton CE, Bacon S, Davy S, Wong AY, Mehrkar A, Tomlinson L, Douglas IJ, Mathur R, Blomquist P, MacKenna B, Ingelsby P, Croker R, Parry J, Hester F, Harper S, DeVito NJ, Hulme W, Tazare J, Goldacre B, Smeeth L, Eggo RM. Case fatality risk of the SARS-CoV-2 variant of concern B.1.1.7 in England, 16 November to 5 February. Euro Surveill 2021; 26:2100256. [PMID: 33739254 PMCID: PMC7976383 DOI: 10.2807/1560-7917.es.2021.26.11.2100256] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [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: 03/04/2021] [Accepted: 03/18/2021] [Indexed: 11/24/2022] Open
Abstract
The SARS-CoV-2 B.1.1.7 variant of concern (VOC) is increasing in prevalence across Europe. Accurate estimation of disease severity associated with this VOC is critical for pandemic planning. We found increased risk of death for VOC compared with non-VOC cases in England (hazard ratio: 1.67; 95% confidence interval: 1.34-2.09; p < 0.0001). Absolute risk of death by 28 days increased with age and comorbidities. This VOC has potential to spread faster with higher mortality than the pandemic to date.
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Affiliation(s)
- Daniel J Grint
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kevin Wing
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Stephen Jw Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - George Hickman
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Emily Nightingale
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chris Bates
- The Phoenix Partnership (TPP), TPP House, Leeds, United Kingdom
| | | | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon Davy
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Angel Ys Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rohini Mathur
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Paula Blomquist
- COVID-19 Outbreak Surveillance Team, Public Health England, London, United Kingdom
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Peter Ingelsby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - John Parry
- The Phoenix Partnership (TPP), TPP House, Leeds, United Kingdom
| | - Frank Hester
- The Phoenix Partnership (TPP), TPP House, Leeds, United Kingdom
| | - Sam Harper
- The Phoenix Partnership (TPP), TPP House, Leeds, United Kingdom
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Will Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - John Tazare
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- These authors contributed equally
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- These authors contributed equally
| | - Rosalind M Eggo
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- These authors contributed equally
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Schultze A, Douglas I. COVID-19 and inhaled corticosteroids—another piece in an expanding puzzle. The Lancet Respiratory Medicine 2021; 9:674-675. [PMID: 33676591 PMCID: PMC8241279 DOI: 10.1016/s2213-2600(21)00076-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/25/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Anna Schultze
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
| | - Ian Douglas
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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36
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Bhaskaran K, Rentsch CT, MacKenna B, Schultze A, Mehrkar A, Bates CJ, Eggo RM, Morton CE, Bacon SCJ, Inglesby P, Douglas IJ, Walker AJ, McDonald HI, Cockburn J, Williamson EJ, Evans D, Forbes HJ, Curtis HJ, Hulme WJ, Parry J, Hester F, Harper S, Evans SJW, Smeeth L, Goldacre B. HIV infection and COVID-19 death: a population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. Lancet HIV 2021; 8:e24-e32. [PMID: 33316211 PMCID: PMC7773630 DOI: 10.1016/s2352-3018(20)30305-2] [Citation(s) in RCA: 273] [Impact Index Per Article: 91.0] [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] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Whether HIV infection is associated with risk of death due to COVID-19 is unclear. We aimed to investigate this association in a large-scale population-based study in England. METHODS We did a retrospective cohort study. Working on behalf of NHS England, we used the OpenSAFELY platform to analyse routinely collected electronic primary care data linked to national death registrations. We included all adults (aged ≥18 years) alive and in follow-up on Feb 1, 2020, and with at least 1 year of continuous registration with a general practitioner before this date. People with a primary care record for HIV infection were compared with people without HIV. The outcome was COVID-19 death, defined as the presence of International Classification of Diseases 10 codes U07.1 or U07.2 anywhere on the death certificate. Cox regression models were used to estimate the association between HIV infection and COVID-19 death; they were initially adjusted for age and sex, then we added adjustment for index of multiple deprivation and ethnicity, and then for a broad range of comorbidities. Interaction terms were added to assess effect modification by age, sex, ethnicity, comorbidities, and calendar time. RESULTS 17 282 905 adults were included, of whom 27 480 (0·16%) had HIV recorded. People living with HIV were more likely to be male, of Black ethnicity, and from a more deprived geographical area than the general population. 14 882 COVID-19 deaths occurred during the study period, with 25 among people with HIV. People living with HIV had higher risk of COVID-19 death than those without HIV after adjusting for age and sex: hazard ratio (HR) 2·90 (95% CI 1·96-4·30; p<0·0001). The association was attenuated, but risk remained high, after adjustment for deprivation, ethnicity, smoking and obesity: adjusted HR 2·59 (95% CI 1·74-3·84; p<0·0001). There was some evidence that the association was larger among people of Black ethnicity: HR 4·31 (95% CI 2·42-7·65) versus 1·84 (1·03-3·26) in non-Black individuals (p-interaction=0·044). INTERPRETATION People with HIV in the UK seem to be at increased risk of COVID-19 mortality. Targeted policies should be considered to address this raised risk as the pandemic response evolves. FUNDING Wellcome, Royal Society, National Institute for Health Research, National Institute for Health Research Oxford Biomedical Research Centre, UK Medical Research Council, Health Data Research UK.
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Affiliation(s)
- Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris J Bates
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - Rosalind M Eggo
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sebastian C J Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Elizabeth J Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Harriet J Forbes
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John Parry
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - Frank Hester
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - Sam Harper
- The Phoenix Partnership, TPP House, Horsforth, Leeds, UK
| | - Stephen J W Evans
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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37
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Rentsch CT, DeVito NJ, MacKenna B, Morton CE, Bhaskaran K, Brown JP, Schultze A, Hulme WJ, Croker R, Walker AJ, Williamson EJ, Bates C, Bacon S, Mehrkar A, Curtis HJ, Evans D, Wing K, Inglesby P, Mathur R, Drysdale H, Wong AYS, McDonald HI, Cockburn J, Forbes H, Parry J, Hester F, Harper S, Smeeth L, Douglas IJ, Dixon WG, Evans SJW, Tomlinson L, Goldacre B. Effect of pre-exposure use of hydroxychloroquine on COVID-19 mortality: a population-based cohort study in patients with rheumatoid arthritis or systemic lupus erythematosus using the OpenSAFELY platform. Lancet Rheumatol 2021; 3:e19-e27. [PMID: 33349815 PMCID: PMC7745258 DOI: 10.1016/s2665-9913(20)30378-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hydroxychloroquine has been shown to inhibit entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into epithelial cells in vitro, but clinical studies found no evidence of reduced mortality when treating patients with COVID-19. We aimed to evaluate the effectiveness of hydroxychloroquine for prevention of COVID-19 mortality, as opposed to treatment for the disease. METHODS We did a prespecified observational, population-based cohort study using national primary care data and linked death registrations in the OpenSAFELY platform, which covers approximately 40% of the general population in England, UK. We included all adults aged 18 years and older registered with a general practice for 1 year or more on March 1, 2020. We used Cox regression to estimate the association between ongoing routine hydroxychloroquine use before the COVID-19 outbreak in England (considered as March 1, 2020) compared with non-users of hydroxychloroquine and risk of COVID-19 mortality among people with rheumatoid arthritis or systemic lupus erythematosus. Model adjustment was informed by a directed acyclic graph. FINDINGS Between Sept 1, 2019, and March 1, 2020, of 194 637 people with rheumatoid arthritis or systemic lupus erythematosus, 30 569 (15·7%) received two or more prescriptions of hydroxychloroquine. Between March 1 and July 13, 2020, there were 547 COVID-19 deaths, 70 among hydroxychloroquine users. Estimated standardised cumulative COVID-19 mortality was 0·23% (95% CI 0·18 to 0·29) among users and 0·22% (0·20 to 0·25) among non-users; an absolute difference of 0·008% (-0·051 to 0·066). After accounting for age, sex, ethnicity, use of other immunosuppressive drugs, and geographical region, no association with COVID-19 mortality was observed (HR 1·03, 95% CI 0·80 to 1·33). We found no evidence of interactions with age or other immunosuppressive drugs. Quantitative bias analyses indicated that our observed associations were robust to missing information for additional biologic treatments for rheumatological disease. We observed similar associations with the negative control outcome of non-COVID-19 mortality. INTERPRETATION We found no evidence of a difference in COVID-19 mortality among people who received hydroxychloroquine for treatment of rheumatological disease before the COVID-19 outbreak in England. Therefore, completion of randomised trials investigating pre-exposure prophylactic use of hydroxychloroquine for prevention of severe outcomes from COVID-19 are warranted. FUNDING Medical Research Council.
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Affiliation(s)
- Christopher T Rentsch
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicholas J DeVito
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Krishnan Bhaskaran
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeremy P Brown
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Schultze
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - William J Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth J Williamson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Chris Bates
- The Phoenix Partnership, Horsforth, Leeds, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kevin Wing
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rohini Mathur
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Angel Y S Wong
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen I McDonald
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Harriet Forbes
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - John Parry
- The Phoenix Partnership, Horsforth, Leeds, UK
| | | | - Sam Harper
- The Phoenix Partnership, Horsforth, Leeds, UK
| | - Liam Smeeth
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian J Douglas
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - William G Dixon
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK
| | - Stephen J W Evans
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Laurie Tomlinson
- Electronic Health Records Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Schultze A, Walker AJ, MacKenna B, Morton CE, Bhaskaran K, Brown JP, Rentsch CT, Williamson E, Drysdale H, Croker R, Bacon S, Hulme W, Bates C, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, Tomlinson L, Mathur R, Wing K, Wong AYS, Forbes H, Parry J, Hester F, Harper S, Evans SJW, Quint J, Smeeth L, Douglas IJ, Goldacre B. Risk of COVID-19-related death among patients with chronic obstructive pulmonary disease or asthma prescribed inhaled corticosteroids: an observational cohort study using the OpenSAFELY platform. Lancet Respir Med 2020; 8:1106-1120. [PMID: 32979987 PMCID: PMC7515601 DOI: 10.1016/s2213-2600(20)30415-x] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early descriptions of patients admitted to hospital during the COVID-19 pandemic showed a lower prevalence of asthma and chronic obstructive pulmonary disease (COPD) than would be expected for an acute respiratory disease like COVID-19, leading to speculation that inhaled corticosteroids (ICSs) might protect against infection with severe acute respiratory syndrome coronavirus 2 or the development of serious sequelae. We assessed the association between ICS and COVID-19-related death among people with COPD or asthma using linked electronic health records (EHRs) in England, UK. METHODS In this observational study, we analysed patient-level data for people with COPD or asthma from primary care EHRs linked with death data from the Office of National Statistics using the OpenSAFELY platform. The index date (start of follow-up) for both cohorts was March 1, 2020; follow-up lasted until May 6, 2020. For the COPD cohort, individuals were eligible if they were aged 35 years or older, had COPD, were a current or former smoker, and were prescribed an ICS or long-acting β agonist plus long-acting muscarinic antagonist (LABA-LAMA) as combination therapy within the 4 months before the index date. For the asthma cohort, individuals were eligible if they were aged 18 years or older, had been diagnosed with asthma within 3 years of the index date, and were prescribed an ICS or short-acting β agonist (SABA) only within the 4 months before the index date. We compared the outcome of COVID-19-related death between people prescribed an ICS and those prescribed alternative respiratory medications: ICSs versus LABA-LAMA for the COPD cohort, and low-dose or medium-dose and high-dose ICSs versus SABAs only in the asthma cohort. We used Cox regression models to estimate hazard ratios (HRs) and 95% CIs for the association between exposure categories and the outcome in each population, adjusted for age, sex, and all other prespecified covariates. We calculated e-values to quantify the effect of unmeasured confounding on our results. FINDINGS We identified 148 557 people with COPD and 818 490 people with asthma who were given relevant respiratory medications in the 4 months before the index date. People with COPD who were prescribed ICSs were at increased risk of COVID-19-related death compared with those prescribed LABA-LAMA combinations (adjusted HR 1·39 [95% CI 1·10-1·76]). Compared with those prescribed SABAs only, people with asthma who were prescribed high-dose ICS were at an increased risk of death (1·55 [1·10-2·18]), whereas those given a low or medium dose were not (1·14 [0·85-1·54]). Sensitivity analyses showed that the apparent harmful association we observed could be explained by relatively small health differences between people prescribed ICS and those not prescribed ICS that were not recorded in the database (e value lower 95% CI 1·43). INTERPRETATION Our results do not support a major role for regular ICS use in protecting against COVID-19-related death among people with asthma or COPD. Observed increased risks of COVID-19-related death can be plausibly explained by unmeasured confounding due to disease severity. FUNDING UK Medical Research Council.
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Affiliation(s)
- Anna Schultze
- London School of Hygiene & Tropical Medicine, London, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Jeremy P Brown
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bates
- The Phoenix Partnership (TPP), TPP House, Leeds, UK
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Helen I McDonald
- London School of Hygiene & Tropical Medicine, London, UK; NIHR Health Protection Research Unit in Immunisation, London, UK
| | | | - Rohini Mathur
- London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Wing
- London School of Hygiene & Tropical Medicine, London, UK
| | - Angel Y S Wong
- London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet Forbes
- London School of Hygiene & Tropical Medicine, London, UK
| | - John Parry
- The Phoenix Partnership (TPP), TPP House, Leeds, UK
| | - Frank Hester
- The Phoenix Partnership (TPP), TPP House, Leeds, UK
| | - Sam Harper
- The Phoenix Partnership (TPP), TPP House, Leeds, UK
| | | | - Jennifer Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Liam Smeeth
- London School of Hygiene & Tropical Medicine, London, UK; NIHR Health Protection Research Unit in Immunisation, London, UK
| | - Ian J Douglas
- London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
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Williamson EJ, Tazare J, Bhaskaran K, Walker AJ, McDonald HI, Tomlinson L, Bacon S, Bates C, Curtis HJ, Forbes H, Minassian C, Morton CE, Nightingale E, Mehrkar A, Evans D, Nicholson BD, Leon D, Inglesby P, MacKenna B, Cockburn J, Davies NG, Hulme W, Morley J, Douglas IJ, Rentsch CT, Mathur R, Wong A, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Grieve R, Harrison D, Steyerberg E, Eggo RM, Diaz-Ordaz K, Keogh R, Evans SJ, Smeeth L, Goldacre B. Study protocol: Comparison of different risk prediction modelling approaches for COVID-19 related death using the OpenSAFELY platform. Wellcome Open Res 2020. [DOI: 10.12688/wellcomeopenres.16353.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
On March 11th 2020, the World Health Organization characterised COVID-19 as a pandemic. Responses to containing the spread of the virus have relied heavily on policies involving restricting contact between people. Evolving policies regarding shielding and individual choices about restricting social contact will rely heavily on perceived risk of poor outcomes from COVID-19. In order to make informed decisions, both individual and collective, good predictive models are required. For outcomes related to an infectious disease, the performance of any risk prediction model will depend heavily on the underlying prevalence of infection in the population of interest. Incorporating measures of how this changes over time may result in important improvements in prediction model performance. This protocol reports details of a planned study to explore the extent to which incorporating time-varying measures of infection burden over time improves the quality of risk prediction models for COVID-19 death in a large population of adult patients in England. To achieve this aim, we will compare the performance of different modelling approaches to risk prediction, including static cohort approaches typically used in chronic disease settings and landmarking approaches incorporating time-varying measures of infection prevalence and policy change, using COVID-19 related deaths data linked to longitudinal primary care electronic health records data within the OpenSAFELY secure analytics platform.
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Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 2020; 17:e1003379. [PMID: 32960880 PMCID: PMC7508372 DOI: 10.1371/journal.pmed.1003379] [Citation(s) in RCA: 211] [Impact Index Per Article: 52.8] [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: 06/11/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States. METHODS AND FINDINGS This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6-60.5) than Hispanic (52.7, 95% CI 52.1-53.4) and White individuals (38.6, 95% CI 38.4-38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85-2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74-1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80-1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73-1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41-2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11-1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health. CONCLUSIONS In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities.
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Affiliation(s)
- Christopher T. Rentsch
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Farah Kidwai-Khan
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Janet P. Tate
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America
| | - Joseph T. King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Melissa Skanderson
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
| | - Ronald G. Hauser
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Christopher I. Jarvis
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mark Holodniy
- VA Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California, United States of America
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kathleen M. Akgün
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Kristina Crothers
- VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington, United States of America
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Matthew S. Freiberg
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Amy C. Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut, United States of America
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 order by 1-- jvdb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 and 7953=utl_inaddr.get_host_address(chr(113)||chr(122)||chr(106)||chr(118)||chr(113)||(select (case when (7953=7953) then 1 else 0 end) from dual)||chr(113)||chr(122)||chr(107)||chr(112)||chr(113))-- qzhh] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 and 7168=cast((chr(113)||chr(113)||chr(120)||chr(98)||chr(113))||(select (case when (7168=7168) then 1 else 0 end))::text||(chr(113)||chr(113)||chr(98)||chr(98)||chr(113)) as numeric)-- flrx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 or (select 2947 from(select count(*),concat(0x717a6a7671,(select (elt(2947=2947,1))),0x717a6b7071,floor(rand(0)*2))x from information_schema.plugins group by x)a)-- ieid] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 and 7592=3802-- bjys] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 rlike (select (case when (4420=4420) then 0x31302e313033382f7334313538362d3032302d323532312d34 else 0x28 end))] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 and 3667=(select (case when (3667=2069) then 3667 else (select 2069 union select 3793) end))-- btqc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 and row(1599,1897)>(select count(*),concat(0x717a6a7671,(select (elt(1599=1599,1))),0x717a6b7071,floor(rand(0)*2))x from (select 5124 union select 5376 union select 2780 union select 4282)a group by x)-- ztlq] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 and 3135=convert(int,(select char(113)+char(113)+char(120)+char(98)+char(113)+(select (case when (3135=3135) then char(49) else char(48) end))+char(113)+char(113)+char(98)+char(98)+char(113)))-- fhdn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020. [DOI: 10.1038/s41586-020-2521-4 rlike (select (case when (3473=3449) then 0x31302e313033382f7334313538362d3032302d323532312d34 else 0x28 end))-- gcyk] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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