Laura North

Background: Childhood residential mobility (RM) has been associated with adverse health and social outcomes. We examined differences in RM by family size and household composition in two diverse, disadvantaged UK populations. Methods: Using electronic health records (EHRs) and anonymised addresses, we examined if household characteristics are associated with RM in north-east London (NEL) and Wales. We conducted a longitudinal study of 240,509 (51.0 per cent male) and 398,959 (51.3 per cent male) children aged 0–13 years in NEL and Wales respectively on 1 January 2015, with complete follow-up until 31 December 2019. We defined RM as at least one change in address during follow-up. We estimated odds ratios (OR) and 95 per cent confidence intervals (CI) for RM by interactions between age group (0–4, 5–9, 10–13 years), number of children in household and household composition, adjusting for demographic, household and area-level characteristics. Results: Overall, 20.6 per cent and 32.1 per cent of children experienced RM. RM was highest in the youngest age group: NEL: 25.3 per cent, 18.7 per cent, 15.6 per cent; Wales: 40.1 per cent, 29.4 per cent, 23.6 per cent. RM was more likely among 10–13-year-olds living with a single adult than two working-age adults (NEL OR: 1.15; 95 per cent CI: 1.07,1.25; Wales: 1.82; 1.73,1.91). Children in households with four or more children were more likely to experience RM than those with no other child among 10–13-year-olds in NEL (1.31; 1.18,1.46) and 5–9-year-olds and 10–13-year-olds in Wales (1.21; 1.14,1.29 and 1.68; 1.56,1.82). Conclusion: RM is more common in early childhood and varies by household composition, region and age group. EHRs can be used to estimate RM using real-world data and have the potential to examine its impact on health and other outcomes.

Background: The COVID‐19 pandemic has profoundly impacted the lives of people living with dementia (PLWD). Mitigating measures have led to extreme social isolation and reduced or limited capacity within routine health and social care services. Using anonymised individual‐level, population‐scale linked electronic healthcare, demographic and mortality records in Wales, we have examined the impact of the COVID‐19 pandemic on all‐cause mortality in PLWD and in older adults living with other comorbid conditions.Method: Using the Secure Anonymised Information Linkage (SAIL) Databank (Lyons et al., 2009), we identified six cohorts of individuals aged 50‐101 and living in Wales on or before 1^st February 2020, with conditions in the following domains: dementia, cardiovascular, respiratory, metabolic, renal, and cerebrovascular. For each, we identified paired samples matched by age and sex using propensity sampling. Evidence for comorbidities were extracted using ICD‐10 and READ codes. We quantified excess mortality in PLWD during the COVID‐19 period (July 2020 – May 2021 at the point of the analysis) by comparing weekly mortality to a baseline rate (2015‐2019 average) and to the population paired sample. We then extracted retrospective datasets across sixteen‐month periods from 2010‐2020. Finally, we estimated all‐cause mortality odds‐ratios for each period and comorbid domain using logistic regression, controlling for age and sex.Result: PLWD had higher risk of all‐cause mortality compared to a matched sample of individuals without dementia (Figure 1a), especially during the first wave of the pandemic (April 2020, Figure 1b), and in older PLWD (Figure 1c). Examining evidence across other comorbid conditions (Figure 2), logistic regression modelling showed the greatest increase in mortality odds among PLWD (Figure 2f) compared to people without dementia, increasing from 4.47 in 2018 to 5.61 in 2020. The magnitude of the increase in odds among people with cardiovascular, metabolic, renal, and cerebrovascular conditions from 2020‐2021 compared to previous years was smaller compared to the increase in PLWD (Figures 2a, 2c‐e).Conclusion: PLWD experienced increased mortality risk compared to those living with other comorbid conditions during 2020. Further work will focus on the composition of death causes and the contribution of other comorbidities to all‐cause mortality among PLWD.

Background: dementia may increase care home residents’ risk of COVID-19, but there is a lack of evidence on this effect and on interactions with individual and care home-level factors. Methods: we created a national cross-sectional retrospective cohort of care home residents in Wales for 1 September to 31 December 2020. Risk factors were analysed using multi-level logistic regression to model the likelihood of SARS-CoV-2 infection and mortality. Results: the cohort included 9,571 individuals in 673 homes. Dementia was diagnosed in 5,647 individuals (59%); 1,488 (15.5%) individuals tested positive for SARS-CoV-2. We estimated the effects of age, dementia, frailty, care home size, proportion of residents with dementia, nursing and dementia services, communal space and region. The final model included the proportion of residents with dementia (OR for positive test 4.54 (95% CIs 1.55–13.27) where 75% of residents had dementia compared to no residents with dementia) and frailty (OR 1.29 (95% CIs 1.05–1.59) for severe frailty compared with no frailty). Analysis suggested 76% of the variation was due to setting rather than individual factors. Additional analysis suggested severe frailty and proportion of residents with dementia was associated with all-cause mortality, as was dementia diagnosis. Mortality analyses were challenging to interpret. Discussion: whilst individual frailty increased the risk of COVID-19 infection, dementia was a risk factor at care home but not individual level. These findings suggest whole-setting interventions, particularly in homes with high proportions of residents with dementia and including those with low/no individual risk factors may reduce the impact of COVID-19.

Background: falls are common in older people, but associations between falls, dementia and frailty are relatively unknown. The impact of the COVID-19 pandemic on falls admissions has not been studied. Aim: to investigate the impact of dementia, frailty, deprivation, previous falls and the differences between years for falls resulting in an emergency department (ED) or hospital admission. Study Design: longitudinal cross-sectional observational study. Setting: older people (aged 65+) resident in Wales between 1 January 2010 and 31 December 2020. Methods: we created a binary (yes/no) indicator for a fall resulting in an attendance to an ED, hospital or both, per person, per year. We analysed the outcomes using multilevel logistic and multinomial models. Results: we analysed a total of 5,141,244 person years of data from 781,081 individuals. Fall admission rates were highest in 2012 (4.27%) and lowest in 2020 (4.27%). We found an increased odds ratio (OR [95% confidence interval]) of a fall admission for age (1.05 [1.05, 1.05] per year of age), people with dementia (2.03 [2.00, 2.06]) and people who had a previous fall (2.55 [2.51, 2.60]). Compared with fit individuals, those with frailty had ORs of 1.60 [1.58, 1.62], 2.24 [2.21, 2.28] and 2.94 [2.89, 3.00] for mild, moderate and severe frailty respectively. Reduced odds were observed for males (0.73 [0.73, 0.74]) and less deprived areas; most deprived compared with least OR 0.75 [0.74, 0.76]. Conclusions: falls prevention should be targeted to those at highest risk, and investigations into the reduction in admissions in 2020 is warranted.

Background: COVID-19 vaccinations have been prioritised for high risk individuals. Aim: Determine individual-level risk factors for care home residents testing positive for SARS-CoV-2. Study design: Longitudinal observational cohort study using individual-level linked data from the Secure Anonymised Information Linkage (SAIL) databank. Setting: Fourteen thousand seven hundred and eighty-six older care home residents (aged 65+) living in Wales between 1 September 2020 and 1 May 2021. Our dataset consisted of 2,613,341 individual-level daily observations within 697 care homes. Methods: We estimated odds ratios (ORs [95% confidence interval]) using multilevel logistic regression models. Our outcome of interest was a positive SARS-CoV-2 PCR test. We included time-dependent covariates for the estimated community positive test rate of COVID-19, hospital inpatient status, vaccination status and frailty. Additional covariates were included for age, sex and specialist care home services. Results: The multivariable regression model indicated an increase in age (OR 1.01 [1.00,1.01] per year), community positive test rate (OR 1.13 [1.12,1.13] per percent increase), hospital inpatients (OR 7.40 [6.54,8.36]), and residents in care homes with non-specialist dementia care (OR 1.42 [1.01,1.99]) had an increased odds of a positive test. Having a positive test prior to the observation period (OR 0.58 [0.49,0.68]) and either one or two doses of a vaccine (0.21 [0.17,0.25] and 0.05 [0.02,0.09], respectively) were associated with a decreased odds. Conclusions: Care providers need to remain vigilant despite the vaccination rollout, and extra precautions should be taken when caring for the most vulnerable. Minimising potential COVID-19 infection for care home residents when admitted to hospital should be prioritised.

Background: defining features of the COVID-19 pandemic in many countries were the tragic extent to which care home residents were affected and the difficulty in preventing the introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was the transfer of patients from hospitals that were experiencing high levels of nosocomial events. Methods: we tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period from March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in case rates following exposure to a hospital discharge using multi-level hierarchical logistic regression and a novel stochastic Hawkes process outbreak model. Findings: in regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI: 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated that approximately 1.8% of hospital discharged patients may have been infected. Interpretation: there is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients and action taken within care homes following transfer all may have contributed to the mitigation. The precise key transmission routes from the community remain to be quantified.

Background: Little is known about mental health problems of children and young people (CYP) involved with public and private law family court proceedings, and how these CYP fare compared to those not involved in these significant disruptions to family life.Aims: This study examined records of depression/anxiety in CYP involved in public and private law proceedings using linked population-level data across Wales.Method: Retrospective e-cohort study. We calculated the incidence of primary-care-recorded depression/anxiety among CYP involved in these proceedings and in a comparison group, using Poisson regression. Depression/anxiety outcomes following proceedings were evaluated using pairwise Cox regression, with age- and gender-matched controls of CYP who had no involvement with the courts.Results: CYP in the public group had twice the risk of depression (adjusted incidence rate ratio aIRR = 2.2; 95% CI 1.9–2.6) and 20% higher risk of anxiety (aIRR = 1.2; 95% CI 1.0–1.5) relative to the comparison group. The private group had 60% higher risk of depression (aIRR = 1.6; 95% CI 1.4–1.7) and 30% higher risk of anxiety (aIRR = 1.3; 95% CI 1.2–1.4). Following private law proceedings, CYP were more likely to have depression (hazard ratio HR = 1.9; 95% CI 1.7–2.1), and anxiety (HR = 1.4; 95% CI 1.2–1.6) than the control group. Following public proceedings, CYP were more likely to have depression (HR = 2.1; 95% CI 1.7–2.5). Incidence of anxiety or depression following court proceedings was around 4%.Conclusions: Findings highlight the vulnerability of CYP involved in family court proceedings and increased risk of depression and anxiety. Schools, health professionals, social and family support workers have a role to play in identifying needs and ensuring CYP receive appropriate support before, during and after proceedings.

IntroductionUnder section 31 of the Children Act 1989, public law care proceedings can be issued if there is concern a child is subject to, or at risk of significant harm, which can lead to removal of a child from parents. Appropriate and effective health and social support are required to potentially prevent some of the need for these proceedings. More comprehensive evidence of the health needs and vulnerabilities of parents will enable enhanced response from family courts and integrated other services. ObjectiveTo examine health vulnerabilities of parents involved in care proceedings in the two-year period prior to involvement. MethodsFamily court data provided by Cafcass Cymru were linked to population-based health records held within the Secure Anonymised Information Linkage Databank. Linked data were available for 8,821 parents of children involved in care proceedings between 2011 and 2019. Findings were benchmarked with reference to a comparison group of parents matched on sex, age, and deprivation (n = 32,006), not subject to care proceedings. Demographic characteristics, overall health service use, and health profiles of parents were examined. Descriptive and statistical tests of independence were used. ResultsNearly half of cohort parents (47.6%) resided in the most deprived quintile. They had higher levels of healthcare use compared to the comparison group across multiple healthcare settings, with the most pronounced differences for emergency department attendances (59.3% vs 37.0%). Health conditions with the largest variation between groups were related to mental health (43.6% vs 16.0%), substance use (19.4% vs 1.6%) and injuries (41.5% vs 23.6%). ConclusionThis study highlights the heightened socioeconomic and health vulnerabilities of parents who experience care proceedings concerning a child. Better understanding of the needs and vulnerabilities of this population may provide opportunities to improve a range of support and preventative interventions that respond to crises in the community.

Background: vaccinations for COVID-19 have been prioritised for older people living in care homes. However, vaccination trials included limited numbers of older people. Aim: we aimed to study infection rates of SARS-CoV-2 for older care home residents following vaccination and identify factors associated with increased risk of infection. Study Design and Setting: we conducted an observational data-linkage study including 14,104 vaccinated older care home residents in Wales (UK) using anonymised electronic health records and administrative data. Methods: we used Cox proportional hazards models to estimate hazard ratios (HRs) for the risk of testing positive for SARS-CoV-2 infection following vaccination, after landmark times of either 7 or 21 days post-vaccination. We adjusted HRs for age, sex, frailty, prior SARS-CoV-2 infections and vaccination type. Results: we observed a small proportion of care home residents with positive polymerase chain reaction (tests following vaccination 1.05% (N = 148), with 90% of infections occurring within 28 days. For the 7-day landmark analysis we found a reduced risk of SARS-CoV-2 infection for vaccinated individuals who had a previous infection; HR (95% confidence interval) 0.54 (0.30, 0.95). For the 21-day landmark analysis, we observed high HRs for individuals with low and intermediate frailty compared with those without; 4.59 (1.23, 17.12) and 4.85 (1.68, 14.04), respectively. Conclusions: increased risk of infection after 21 days was associated with frailty. We found most infections occurred within 28 days of vaccination, suggesting extra precautions to reduce transmission risk should be taken in this time frame.