Primary care service use towards end of life among patients who died before and during the COVID-19 epidemic: a nationwide cohort study using the Clinical Practice Research DataLink

Date of ISAC Approval: 
07/07/2020
Lay Summary: 
The epidemic of coronavirus disease 2019 (COVID-19) has been causing a wide-spread disruption across all care settings including primary care since March 2020 in the United Kingdom. Primary care plays an important role in managing and coordinating the care for patients who are actively dying and in need of support most, this is particularly important when lockdown and social distancing rules are being enforced. There is little data on how the primary care for patients who are approaching end-of-life has been being impacted by the COVID-19 epidemic. We propose to use real-world data collected during the process of primary care to fill this knowledge gap. We will examine the difference between the patients who died before and during the epidemic, for what reasons patients were interacting with their GPs, what and how GPs had been providing services to patients towards end-of-life. We will use this information to assess the change of care needs in the context of the COVID-19 epidemic and how well the primary care service use was matching to the changing needs. We will explore how various factors interact with each other impacting why and how people approaching end-of-life used primary care services. This information is key to monitor care equality, timely identify emerging care inequality, and how to maintain high-quality end-of-life care in current and future public health emergencies.
Technical Summary: 
Background: the epidemic of coronavirus disease 2019 (COVID-19) has been causing a wide-spread disruption across all care settings including primary care since March 2020 in the United Kingdom. Primary care plays an important role in managing and coordinating the care for patients who are approaching the end of life. There is little data to understand how the COVID-19 epidemic influence these patients use of primary care services. Aim: to evaluate and compare reasons for, patterns of and factors associated with the use of primary care services in patients who died before and during the COVID-19 epidemic. Study design: a nationwide comparative cohort study. Data and methods: the data source is the Clinical Practice Research DataLink. All patients who died before and during the COVID-19 epidemic since 01/01/2019 will be included. The outcomes to be measured: GP consultation (primary), GP prescription, and GP referral. Independent variables include patient socio-demographic and clinical characteristics, with palliative care needs recorded (1) or not (0), and practice-level characteristics. The outcome and independent variables as well as other details (e.g. type, location) on GP consultations will be described using descriptive statistics by the period of patients’ deaths (before & during). The factors associated with primary care service use will be identified using a generalised linear mixed model, accounting for the hierarchical structure of the data. We will also use a structural equation model/artificial neural network to explore how various factors interact with each other to affect primary care service use. The robustness of the findings will be assessed with sensitivity analysis. Bonferroni correction will be used to control for multiple testing. Implications: the data generated in this study are key to understand care needs and service gaps, identify and monitor care inequality in primary care, maintain the quality of end-of-life care in current and future public health emergencies.
Health Outcomes to be Measured: 
GP consultation (primary); GP Prescription; GP Referral.
Collaborators: 

Wei Gao - Chief Investigator - King’s College London
Emeka Chukwusa - Collaborator - King’s College London
Irene Higginson - Collaborator - King’s College London
Martin Gulliford - Collaborator - King’s College London
Stephen Barclay - Collaborator - King’s College London
Wei Gao - Corresponding Applicant - King’s College London

Linkages: 
2011 Rural-Urban (Non-standard) LSOA;Practice IMD (Standard)