Abstract
Background: Dexamethasone was the first intervention proven to reduce mortality in patients with COVID-19 being treated in hospital. We aimed to evaluate the adoption of corticosteroids in the treatment of COVID-19 in the UK after the RECOVERY trial publication on June 16, 2020, and to identify discrepancies in care.
Methods: We did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260.
Findings: Between June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 [86·6%] of 12 909 vs 36 415 [72·4%] of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 [95% CI 0·70–0·89], p=0·0001, for 70–79 years; 0·52 [0·46–0·58], p<0·0001, for >80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75–80% in January, 2021.
Interpretation: Implementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered.
Funding: UK National Institute for Health Research and UK Medical Research Council.
Methods: We did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260.
Findings: Between June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 [86·6%] of 12 909 vs 36 415 [72·4%] of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 [95% CI 0·70–0·89], p=0·0001, for 70–79 years; 0·52 [0·46–0·58], p<0·0001, for >80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75–80% in January, 2021.
Interpretation: Implementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered.
Funding: UK National Institute for Health Research and UK Medical Research Council.
| Original language | English |
|---|---|
| Pages (from-to) | e220-e234 |
| Number of pages | 15 |
| Journal | The Lancet Digital Health |
| Volume | 4 |
| Issue number | 4 |
| Early online date | 22 Mar 2022 |
| DOIs | |
| Publication status | Published - Apr 2022 |
Bibliographical note
Acknowledgments:This study is supported by grants from the NIHR (award CO-CIN-01), the MRC (grant MC_PC_19059), the NIHR Imperial Biomedical Research Centre (grants P45058 and IS-BRC-1215-20013), the NIHR HPRU in Respiratory Infections at Imperial College London and NIHR HPRU in Emerging and Zoonotic Infections at the University of Liverpool, both in partnership with Public Health England (NIHR award 200907), the Wellcome Trust and the UK Department for International Development (215091/Z/18/Z), the Bill & Melinda Gates Foundation (OPP1209135), the Liverpool Experimental Cancer Medicine Centre (grant reference C18616/A25153), and the EU Platform for European Preparedness Against (Re-)emerging Epidemics 1 (FP7 project 602525). The NIHR Clinical Research Network provided infrastructure support for this research. This research was funded, in part, by the Wellcome Trust. RHM reports grants from BREATHE, the health data research hub for respiratory health (MC_PC_19004). BREATHE is funded through the UK Research and Innovation Industrial Strategy Challenge Fund and is delivered by Health Data Research UK. ABD acknowledges funding from the Wellcome Trust (216606/Z/19/Z0). LT is supported by a Wellcome Trust fellowship (205228/Z/16/Z). PJMO is supported by a NIHR Senior Investigator Award (award 201385). The views expressed are those of the authors and not necessarily those of the DHSC, the Department for International Development, the NIHR, the MRC, the Wellcome Trust, or Public Health England. Investigators were independent from funders. ISARIC4C CCP-UK data are provided by patients and collected by the UK National Health Service as part of their care. Although there was no direct involvement from patients or the public, quality improvement is paramount in ensuring the reliability of the health-care system that aims to maximise benefit and minimise harm to patients. This research was conducted as part of an urgent public health study in response to an emergency, meaning there was insufficient time for public involvement before data collection commenced. We are extremely grateful to the 2648 front-line NHS clinical and research staff and volunteer medical students who collected these data under challenging circumstances, and the generosity of the participants and their families for their individual contributions in these difficult times. We also acknowledge the support of Jeremy J Farrar (Wellcome Trust, London, UK) and Nahoko Shindo (WHO, Geneva, Switzerland).