BackgroundStudies suggest that certain black and Asian minority ethnic groups experience poorer outcomes from COVID-19, but these studies have not provided insight into potential reasons for this. We hypothesised that outcomes would be poorer for those of South Asian ethnicity hospitalised from a confirmed SARS-CoV-2 infection, once confounding factors, health-seeking behaviours and community demographics were considered, and that this might reflect a more aggressive disease course in these patients.MethodsPatients with confirmed SARS-CoV-2 infection requiring admission to University Hospitals Birmingham NHS Foundation Trust (UHB) in Birmingham, UK between 10 March 2020 and 17 April 2020 were included. Standardised admission ratio (SAR) and standardised mortality ratio (SMR) were calculated using observed COVID-19 admissions/deaths and 2011 census data. Adjusted HR for mortality was estimated using Cox proportional hazard model adjusting and propensity score matching.ResultsAll patients admitted to UHB with COVID-19 during the study period were included (2217 in total). 58% were male, 69.5% were white and the majority (80.2%) had comorbidities. 18.5% were of South Asian ethnicity, and these patients were more likely to be younger and have no comorbidities, but twice the prevalence of diabetes than white patients. SAR and SMR suggested more admissions and deaths in South Asian patients than would be predicted and they were more likely to present with severe disease despite no delay in presentation since symptom onset. South Asian ethnicity was associated with an increased risk of death, both by Cox regression (HR 1.4, 95% CI 1.2 to 1.8), after adjusting for age, sex, deprivation and comorbidities, and by propensity score matching, matching for the same factors but categorising ethnicity into South Asian or not (HR 1.3, 95% CI 1.0 to 1.6).ConclusionsThose of South Asian ethnicity appear at risk of worse COVID-19 outcomes. Further studies need to establish the underlying mechanistic pathways.

Background The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR. Methods The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019. Results A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001). Conclusion During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

ObjectiveTo evaluate the effectiveness of reminder letters informed by social normative theory (a type of ‘nudge theory’) on uptake of seasonal influenza vaccination by front-line hospital staff.DesignIndividually randomised controlled trial.SettingA large acute care hospital in England.ParticipantsFront-line staff employed by the hospital (n=7540) were randomly allocated to one of four reminder types in a factorial design.InterventionsThe standard letter included only general information directing the staff to take up the vaccine. A second letter highlighted a type of social norm based on peer comparisons. A third letter highlighted a type of social norm based on an appeal to authority. A fourth letter included a combination of the social norms.Main outcome measureThe proportion of hospital staff vaccinated on-site.ResultsVaccine coverage was 43% (812/1885) in the standard letter group, 43% (818/1885) in the descriptive norms group, 43% (814/1885) in the injunctive norms group and 43% (812/1885) in the combination group. There were no statistically significant effects of either norm or the interaction. The OR for the descriptive norms factor is 1.01 (0.89–1.15) in the absence of the injunctive norms factor and 1.00 (0.88–1.13) in its presence. The OR for the injunctive norms factor is 1.00 (0.88–1.14) in the absence of the descriptive norms factor and 0.99 (0.87–1.12) in its presence.ConclusionsWe find no evidence that the uptake of the seasonal influenza vaccination is affected by reminders using social norms to motivate uptake.

Objectives. To determine if specific ethnic groups are at higher risk of mortality from COVID19 infection. Design. Retrospective cohort study Setting. University Hospitals Birmingham NHS Foundation Trust (UHB) in Birmingham, UK Participants. Patients with confirmed SARS CoV 2 infection requiring admission to UHB between 10th March 2020 and 17th April 2020 Exposure. Ethnicity Main outcome measures. Standardised Admission Ratio (SAR) and Standardised Mortality Ratio (SMR) for each ethnicity was calculated using observed sex specific age distributions of COVID19 admissions/deaths and 2011 census data for Birmingham/Solihull. Hazard Ratio (aHR) for mortality was estimated for each ethnic group with white population as reference group, using Cox proportional hazards model adjusting for age, sex, social deprivation and co-morbidities, and propensity score matching. Results. 2217 patients admitted to UHB with a proven diagnosis of COVID19 were included. 58.2% were male, 69.5% White and the majority (80.2%) had co morbidities. 18.5% were of South Asian ethnicity, and these patients were more likely to be younger (median age 61 years vs.77 years), have no co morbidities (27.8% vs. 16.6%) but a higher prevalence of diabetes mellitus (48.0% vs 28.2%) than White patients. SAR and SMR suggested more admissions and deaths in South Asian patients than would be predicted. South Asian patients were also more likely to present with severe disease despite no delay in presentation since symptom onset. South Asian ethnicity was associated with an increased risk of death; both by Cox regression (Hazard Ratio 1.66 (95%CI 1.32 to 2.10)) after adjusting for age, sex, deprivation and comorbidities and by propensity score matching, (Hazard ratio 1.68 (1.33 to 2.13), using the same factors but categorising ethnicity into South Asian or not. Conclusions. Current evidence suggests those of South Asian ethnicity may be at risk of worse COVID19 outcomes, further studies need to establish the underlying mechanistic pathways.