Ensuring that evidence survives the pandemic
Truth may be the first casualty of war and, in Professor Nick Bosanquet’s mind, evidence seems to be the first casualty of a new pandemic. He sets out three priorities for urgent research that must be addressed in the wake of Covid-19.
As international evidence continues to grow, so does the variety in global outcomes on Covid-19. In Germany there have been 103 deaths per million inhabitants compared to 579 per million in the UK. Within the US, San Francisco has had 50 deaths compared to 21,000 in New York. Some of the better results have largely been down to more robust prevention; but there are key differences in direct patient treatment that have also had an effect.
Variety in care setting
How do outcomes differ between patients treated at home and those treated in hospital? There is already some highly concerning evidence on ventilator treatment outcomes, with a mortality rate of 50-70 per cent being seen in hospitals. The use of ventilators is a highly invasive technique which has never been used to such a scale on elderly, high risk patients.
We need more evidence on the impact of early diagnosis. More proactive testing programs, like that seen in Germany, seem to have resulted in earlier diagnosis. We need evidence too on the patient experience in different settings, at home, in hospital and in care homes. How have treatment patterns differed and how did responsibility for care differ between the same settings?
We also need evidence on treatment programmes between ethnic groups. Public Health England has confirmed the high rates of infection and mortality for black and ethnic minorities – but we are a long way from understanding the reasons for this. The dedication of health and social care staff has been extraordinary, but we must be realistic about the fact that UK outcomes in excess mortality have been poor. There may be room for debate about the results in each country, but the UK mortality rate is simply too high.
Rehabilitation from Covid
This virus is still an extremely new one and there is much we still do not know; one area is in how we best rehabilitate patients who are recovering from serious Covid-19 infections. There are perhaps learnings we can take from already successful programs already used for cardiac rehab and for AIDs patients, which include a variety of therapies and lifestyle programs. These programs have offered freedom for patients and have improved their quality of life, helping many to stay in work (around 80 per cent of patients who are HIV positive are in work).
There are going to be new choices about supportive drug therapies to aid Covid recovery, but any such program must be directed by a desire to improve a person’s quality of life. This is where integrated care could come into play, harnessing digital resources now being fully utilised across primary care to help with the longer-term support. We have already seen the development of ‘Virtual Wards’ being implemented in hospitals; we should likewise see the development of ‘Virtual Support and Rehab’ programmes within the community. There is much scope here for increasing carer support and for voluntary groups to become involved. We need to develop options for a positive approach to rehabilitation and embed a sense of flexibility to meet the new problems which can emerge from what is still a very novel virus.
Protecting the most vulnerable
For the first time in the NHS there has been an agreed identification of 1.5 million high risk patients. We need evidence on outcomes during the long period of quarantine. Did this fairly extreme measure reduce infection rates and improve survival? What were the negative effects of social isolation upon people’s health? As we look to resume some sort of ‘normality’ of care in the UK, these patients will be increasingly key service users over the next decade. Now that they have been identified there has to be longer term support programmes to improve health and prevent admissions.
There is great opportunity here. Perhaps this mass shielding policy could really get the wheels turning on integrated care. With primary care having a leading role in managing these high-risk patients – shielding could be the start of regular contact and support programmes.
Filling the Evidence Gap
Each of these three evidence priorities point towards the need for a common change of method for research, a more proactive form that involves the close follow up of patients in a community setting rather than selection of small groups in clinical trials.
I was Chief Investigator for part of the Salford Lung Study, which was based on collaboration between primary care teams, the Salford NHS Trust and GSK. It was a community-based trial of different therapies for Salford-based patients living with chronic obstructive pulmonary disease (COPD) and asthma. We were able to produce valuable evidence on actual effects on patients, covering both the outcomes and risks associated with each therapy. We need to see more proactive research like this to inform us how best to help patients get over Covid-19.
In all these three areas there is scope for Trusts and Integrated Care Networks to carry out pioneering research. We must connect post pandemic care with a new kind of expanding evidence base – community based trials that harness local expertise should be the way forward after this crisis.
Nick Bosanquet is Professor of Health Policy at Imperial College London.