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Research

Risks of covid-19 hospital admission and death for people with learning disability: population based cohort study using the OpenSAFELY platform

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1592 (Published 15 July 2021) Cite this as: BMJ 2021;374:n1592

Linked Editorial

Covid 19: People with learning disabilities are highly vulnerable

Read our latest coverage of the coronavirus pandemic
  1. Elizabeth J Williamson, professor of biostatistics and health data science1,
  2. Helen I McDonald, clinical assistant professor12,
  3. Krishnan Bhaskaran, professor of statistical epidemiology1,
  4. Alex J Walker, epidemiologist3,
  5. Sebastian Bacon, chief technical officer3,
  6. Simon Davy, software developer3,
  7. Anna Schultze, research fellow1,
  8. Laurie Tomlinson, associate professor1,
  9. Chris Bates, director of research and analytics4,
  10. Mary Ramsay, head of immunisation25,
  11. Helen J Curtis, postdoctoral researcher3,
  12. Harriet Forbes, research fellow6,
  13. Kevin Wing, assistant professor1,
  14. Caroline Minassian, assistant professor1,
  15. John Tazare, doctoral student1,
  16. Caroline E Morton, epidemiologist3,
  17. Emily Nightingale, research fellow1,
  18. Amir Mehrkar, honorary clinical researcher3,
  19. Dave Evans, software developer3,
  20. Peter Inglesby, consultant engineer3,
  21. Brian MacKenna, honorary clinical researcher3,
  22. Jonathan Cockburn, developer4,
  23. Christopher T Rentsch, assistant professor1,
  24. Rohini Mathur, assistant professor1,
  25. Angel Y S Wong, assistant professor1,
  26. Rosalind M Eggo, associate professor1,
  27. William Hulme, researcher3,
  28. Richard Croker, honorary research fellow3,
  29. John Parry, clinical director4,
  30. Frank Hester, chief executive officer4,
  31. Sam Harper, developer4,
  32. Ian J Douglas, professor of pharmacoepidemiology1,
  33. Stephen J W Evans, professor of Pharmacoepidemiology1,
  34. Liam Smeeth, professor of clinical epidemiology1,
  35. Ben Goldacre, director2,
  36. Hannah Kuper, professor of epidemiology1
  1. 1London School of Hygiene and Tropical Medicine, London, UK
  2. 2National Institute for Health Research (NIHR) Health Protection Research Unit in Vaccines and Immunisation, London, UK
  3. 3The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  4. 4TPP, TPP House, Horsforth, Leeds, UK
  5. 5Public Health England, London, UK
  6. 6University of Bristol, Bristol, UK
  1. Correspondence to: B Goldacre ben.goldacre{at}phc.ox.ac.uk (or @bengoldacre on Twitter)
  • Accepted 9 June 2021

Abstract

Objective To assess the association between learning disability and risk of hospital admission and death from covid-19 in England among adults and children.

Design Population based cohort study on behalf of NHS England using the OpenSAFELY platform.

Setting Patient level data were obtained for more than 17 million people registered with a general practice in England that uses TPP software. Electronic health records were linked with death data from the Office for National Statistics and hospital admission data from NHS Secondary Uses Service.

Participants Adults (aged 16-105 years) and children (<16 years) from two cohorts: wave 1 (registered with a TPP practice as of 1 March 2020 and followed until 31 August 2020); and wave 2 (registered 1 September 2020 and followed until 8 February 2021). The main exposure group consisted of people on a general practice learning disability register; a subgroup was defined as those having profound or severe learning disability. People with Down’s syndrome and cerebral palsy were identified (whether or not they were on the learning disability register).

Main outcome measure Covid-19 related hospital admission and covid-19 related death. Non-covid-19 deaths were also explored.

Results For wave 1, 14 312 023 adults aged ≥16 years were included, and 90 307 (0.63%) were on the learning disability register. Among adults on the register, 538 (0.6%) had a covid-19 related hospital admission; there were 222 (0.25%) covid-19 related deaths and 602 (0.7%) non-covid deaths. Among adults not on the register, 29 781 (0.2%) had a covid-19 related hospital admission; there were 13 737 (0.1%) covid-19 related deaths and 69 837 (0.5%) non-covid deaths. Wave 1 hazard ratios for adults on the learning disability register (adjusted for age, sex, ethnicity, and geographical location) were 5.3 (95% confidence interval 4.9 to 5.8) for covid-19 related hospital admission and 8.2 (7.2 to 9.4) for covid-19 related death. Wave 2 produced similar estimates. Associations were stronger among those classified as having severe to profound learning disability, and among those in residential care. For both waves, Down’s syndrome and cerebral palsy were associated with increased hazards for both events; Down’s syndrome to a greater extent. Hazard ratios for non-covid deaths followed similar patterns with weaker associations. Similar patterns of increased relative risk were seen for children, but covid-19 related deaths and hospital admissions were rare, reflecting low event rates among children.

Conclusions People with learning disability have markedly increased risks of hospital admission and death from covid-19, over and above the risks observed for non-covid causes of death. Prompt access to covid-19 testing and healthcare is warranted for this vulnerable group, and prioritisation for covid-19 vaccination and other targeted preventive measures should be considered.

Footnotes

  • Contributors: BG conceived the platform and the approach; BG and LS led the project overall and are guarantors. Contributions are as follows: design, EJW, HIM, HK, SJWE; data curation: CB, JP, JC, SH, SB, DE, PI, CEM; analysis, EJW, KB, AJW, CEM; funding acquisition: BG, LS; information governance: AM, BG, CB, JP; methodology: EJW, HIM, HK, SJWE, KB, AJW, BG, LS, CB, JP, JC, SH, SB, DE, PI, CEM; disease category conceptualisation and codelists: CEM, AJW, PI, SB, DE, CB, JC, JP, SH, HJC, KB, SB, AM, BM, LT, IJD, HIM, RM, HF; ethics approval: HJC, EJW, LS, BG; project administration: CEM, HJC, CB, SB, AM, LS, BG; resources: BG, LS, FH; software: SB, DE, PI, AJW, CEM, SD, CB, FH, JC, SH; supervision: BG, LS, SB; writing (original draft): EJW, HK, HIM, SJWE. All authors were involved in design and conceptual development and reviewed and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. LS, BG and HK are joint principal investigators; EJW and HIM are joint first authors.

  • Funding: This work was supported by the Medical Research Council (MRC) grant MR/V015737/1. TPP provided technical expertise and infrastructure within their data centre pro bono in the context of a national emergency. EJW was supported by MRC project grant MR/S01442X/1. HIM and MR are funded by the National Institute for Health Research (NIHR) Health Protection Research Unit in Vaccines and Immunisation, a partnership between Public Health England and the London School of Hygiene and Tropical Medicine. HK was supported by funding from the PENDA grant from the Foreign, Commonwealth and Development Office. BG’s work on better use of data in healthcare more broadly is currently funded in part by National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, NIHR Applied Research Collaboration Oxford and Thames Valley, the Mohn-Westlake Foundation, NHS England, and the Health Foundation; all DataLab staff are supported by BG’s grants on this work. The views expressed are those of the authors and not necessarily those of the NIHR, NHS England, Public Health England or the Department of Health and Social Care. Funders had no role in the study design, collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare the following: support from the Medical Research Council, TPP, NIHR Oxford Biomedical Research Centre, NIHR Applied Research Collaboration Oxford and Thames Valley, Mohn-Westlake Foundation, NHS England, NIHR Health Protection Research Unit in Vaccines and Immunisation, the Foreign, Commonwealth and Development Office, and the Health Foundation for the submitted work. EJW has received payments from AstraZeneca for providing training, unrelated to the submitted work. BG has received research funding from the Laura and John Arnold Foundation, the NHS National Institute for Health Research (NIHR), the NIHR School of Primary Care Research, the NIHR Oxford Biomedical Research Centre, the Mohn-Westlake Foundation, NIHR Applied Research Collaboration Oxford and Thames Valley, the Wellcome Trust, the Good Thinking Foundation, Health Data Research UK (HDRUK), the Health Foundation, and the World Health Organization; he also receives personal income from speaking and writing for lay audiences on the misuse of science. IJD has received unrestricted research grants and holds shares in GlaxoSmithKline (GSK) and holds grants from NIHR. LS reports grants from Wellcome, MRC, NIHR, UK Research and Innovation (UKRI), British Council, GSK, British Heart Foundation, and Diabetes UK outside this work. AS is employed by the London School of Hygiene and Tropical Medicine (LSHTM) on a fellowship sponsored by GSK. KB holds a Sir Henry Dale fellowship jointly funded by Wellcome and the Royal Society. AYSW holds a fellowship from BHF. RM holds a Sir Henry Wellcome Fellowship funded by the Wellcome Trust. HF holds a UKRI fellowship. RME is funded by HDRUK and the MRC.

  • Information governance: NHS England is the data controller; TPP is the data processor; and the key researchers on OpenSAFELY are acting on behalf of NHS England. This implementation of OpenSAFELY is hosted within the TPP environment which is accredited to the ISO 27001 information security standard and is NHS IG Toolkit compliant4243; patient data have been pseudonymised for analysis and linkage using industry standard cryptographic hashing techniques; all pseudonymised datasets transmitted for linkage onto OpenSAFELY are encrypted; access to the platform is through a virtual private network (VPN) connection, restricted to a small group of researchers; the researchers hold contracts with NHS England and only access the platform to initiate database queries and statistical models; all database activity is logged; only aggregate statistical outputs leave the platform environment following best practice for anonymisation of results such as statistical disclosure control for low cell counts.44 The OpenSAFELY research platform adheres to the obligations of the UK General Data Protection Regulation (GDPR) and the Data Protection Act 2018. In March 2020, the Secretary of State for Health and Social Care used powers under the UK Health Service (Control of Patient Information) Regulations 2002 (COPI) to require organisations to process confidential patient information for the purposes of protecting public health, providing healthcare services to the public and monitoring and managing the covid-19 outbreak and incidents of exposure; this sets aside the requirement for patient consent.45 Taken together, these provide the legal bases to link patient datasets on the OpenSAFELY platform. GP practices, from which the primary care data are obtained, are required to share relevant health information to support the public health response to the pandemic, and have been informed of the OpenSAFELY analytics platform.

  • The lead authors (BG and LS) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: Dissemination of findings will be undertaken through a variety of routes. A lay summary and Easyread summary aimed at people with learning disability will be made available on the OpenSAFELY and HPRU in Vaccines and Immunisation websites (https://opensafely.org/ and https://immunisation.hpru.nihr.ac.uk/).

  • Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

All data were linked, stored and analysed securely within the OpenSAFELY platform (https://opensafely.org/). Data include pseudonymised data such as coded diagnoses, drugs, and physiological parameters. No free text data are included. All code is shared openly for review and reuse under MIT open license (https://github.com/opensafely/absolute-risks-covid-research). Detailed pseudonymised patient data are potentially reidentifiable and therefore not shared. We rapidly delivered the OpenSAFELY data analysis platform without prior funding to deliver timely analyses on urgent research questions in the context of the global covid-19 health emergency: now that the platform is established we are developing a formal process for external users to request access in collaboration with NHS England; details of this process will be published shortly on https://opensafely.org/.

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This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

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